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SURGICAL  DIFFERENTIALS 


BY 


J.  W.  DRAPER  MAURY,  M.D, 

R0CKEFEL1.KR    INSTITUTE   RESEARCH    FELLOW    IN    THE     LABORATORY    OF 
EXPERIMENTAL    SURGERY 

COLUMBIA    u!NIVERSITY 

NEW    YORK    CITY. 


ILLUSTRATED. 


published  by 
James  T.   Dougherty, 

409  &  411  West  59th  Street, 
.    -     NEW  YORK  CITY.    '■ 

1^04     ' 


Copyrighted,   1904, 


J.  W.  DRAPER  MAURY,  M.  D, 


THEO.  GAU8'  SONS,  Pbintebs. 

42  Fbanklin  Stbekt, 

NEW  YORK. 


TO    MY    MOTHER. 


PREFACE. 

"Diagnosis"  has  for  some  time  been  accepted  as  meaning 
"Differential  Diagnosis."  This  term  is  too  long  for  conveni- 
ent iise  and  of  the  two  words,  clearness  seems  to  demand  that 
"diagnosis"  be  dropped.  This  is  offered  as  an  explanation  of 
the  title  of  this  book. 

The  subject  matter  has  been  compiled  with  but  a  single 
purpose.  This  is  to  present  to  students  intending  to  enter  the 
competitive  examinations  of  the  New  York  Hospitals,  a  well- 
tried  scheme  and  its  mode  of  application.  It  is  not  the  actual 
learning  of  surgical  facts  but  their  selection  and  grouping 
which  is  most  difficult  to  the  student. 

In  the  opinion  of  over  one  hundred  graduates  who  during 
the  past  six  years  secured  hospital  positions,  the  ability  to  apply 
this  scheme  was  the  primary  cause  of  their  success.  These 
pages  represent  simply  an  effort  to  present  as  tersely  as  possible 
the  system  which  has  proved  so  highly  efficacious.  It  will 
therefore  be  seen  that  no  attempt  to  make  a  text-book  or 
book  of  reference  has  been  thought  of. 

Ability  to  sketch  rough  outlines  in  place  of  giving 
long  word  answers  has  always  been  very  helpful  in  secur- 
ing hospital  positions.  In  recognition  of  this,  forty  graphic 
illustrations  have  been  introduced.  They  were  made  by  Dr. 
Chas.  K.  Stillman,  a  successful  graduate  of  last  year.  Hav- 
ing been  made  by  a  student  they  can  be  duplicated  by  a  stu- 
dent, for  they  have  been  drawn  with  studied  simplicity  and  it 
is  believed,  with  accuracy.  Except  in  three  or  four  instances 
they  are  entirely  original; — I  cannot  too  cordially  thank  Dr. 
Stillman  for  his  care,  or  endorse  his  work  too  highl}-. 


Copies  of  some  recent  hospital  examination  papers  have 
been  added,  in  the  interest  of  stndents  at  Universities  ontside 
of  New  York  City. 

The  Differentials  have  been  made  with  care  and  by  pains- 
taking reference  to  leading  text-books.  It  is  feared,  neverthe- 
less, that  many  errors  may  be  found.  These  Differentials  have 
been  chosen  with  the  intention  of  indicating  the  general  broad 
trend  of  to-day's  hospital  questions.  The  time  for  memorizing 
special  material  for  each  examiner  is  happily  past  and  with  it 
the  value  of  the  obnoxious  "quiz  compend.'"  Examiners  no 
longer  ask  for  narrow  isolated  facts  but  require  the  broad  prac- 
tical Diiferential. 

Dr.  Jos.  A.  Blake,  Dr.  Geo.  E.  Brewer,  Dr.  R.  H.  M. 
Dawbarn,  Dr.  John  Rogers  and  Dr.  L.  A.  Stimson  may 
recognize  in  the  text  some  of  their  own  familiar  aphorisms. 
The  author  wishes  to  acknowledge  the  debt  which  he  owes 
these  Teachers  of  Surgery. 

J.  W.  Draper  Maury. 
September  1st,  1904. 


CHAPTER  I. 
SCHEME. 

A  clear  and  uniform  recitation  scheme  is  essential  to  every 
student  of  medicine.  This  is  particularly  true  of  those  who 
enter  competitive  hospital  examinations. 

For  more  general  surgical  diseases  the  same  scheme  may 
be  applied  which  is  universally  used  in  the  practice  of  medicine. 

-,      T-A  (  Simple — Such  as  is  given  in  a  modern  gen- 

1 — Definition    j.  '■  ,    ,.° .  ^ 

(  eral  dictionary. 

r  Predisposing — Age,  sex,  race,  color, 

^     ,-,  j       occupation,   social  status,   climate. 

2 — Etiology   ■{  r  >  ,  ^ 

I    Exciting — Trauma  due  to    r     •  i 

1^  ^  \   violence. 

o     T->  i  Gross. 

3 — Pathology    -'.-.,. 

I  Minute. 

Subjective  or        I  c       o   u      i  t 

^  -"i  o         .-  ^    r  See  Sub-scheme  I 

General  Symptoms  ) 

.      o  1   Inspection 

4 — Symptomatology  <        rw  •     ^-  -ni^- 

j        Objective  or         !    Palpation 

j    Local    Symptoms    {    Percussion 

1  J    Auscultation 

5 — DiFf-ERENTiALS^^— (3.ee  Sub-scheme  II) 

,.     r^  o  (  Immediate,   mediate    and 

0 — Complications    and  Sequelae    \  ' 

I  remote 

7-  Prognosis  \  Mediaff^^  \    ^^  ^^  ^'^^  and  return  of  function 
(Remote        j  of  injured  part 

f  J  Nurse 

I    Medical    V  Feed 
8 — Treatment   -:j  )  Stimulate 


o        -1      Pallative 
Surgical  r  r>    1-     i 
^         )  Radical 


SCHEME. 


SUB-SCHEME  I. 

Many  surgical  lesions,  however,  require  further  detail 
than  .this  familiar  scheme  affords. 

In  giving  subjective  symptoms,  for  example,  it  has  been 
found  convenient  to  follow  the  course  of  a  particle  of  food 
through  the  body.  All  the  patient  complains  of  in  the  usual 
surgical  lesions  is  pain  or  disability.  One  or  both  of  these 
symptoms  may  occur  in  the 


1,  Mouth 

2,  Pharynx 

3,  Esophagus 

4,  Stomach 

5,  Small  and  great  gut 

6,  Liver  (Jaundice)  or  other 
glands 

7,  Here  the  food  enters  the 
blood  from  which  indi- 
rectly is  derived  the 
T.  P.  R. 


8,  Heart 

9,  Lungs 

10,  Brain 

11,  Special  senses 

12,  Peripheral  nerves 

13,  Kidneys  and  G.  U. 

14,  Extremities 


SUB-SCHEME  II. 

1 — HisTOKic   Differentials. 

a.  History  of  Tumor,   Injury,   Disease  or    Malformation. 

Note. — T.  I.  D.  as  used  in  prescription  writing,  convenient  way 
to  remember  this. 

b.  History  of  previous  Injury,  Disease  or  Operation. 

c.  Age,  Sex,  Race,  Occuption,  Social  State,  Climate, 


2 — Subjective  Differentials. 
a.   Pain — Local  and  referred. 


b,    Disftbility 
i\   Vomiting 
d.   Bladder 
and  Rectum 


e^  Jaundice 
/,   T.  P.  R. 


Ap j  Important  always  to  give  the  actual 

/  figures.      Never  say  elevated  or  de- 
pressed. 


120  is  the  danger  line  of  the  pulse. 
Pulse  has  six  characteristics:  Force, 
Frequency,  Rhythm,  Lengfth,  Full- 
ness, Compressibility.  The  first  three 
are  determined  by  the  heart,  the 
last  three  by  the  condition  of  the 
vessel  wall. 


SCHEME.     •  9^ 

f   Central   (vertigo,   delirium,   con- 
.   -^T  .  ,  ^       .        ,    j  sciousness,  convulsions) 

^ '  "^      V     s  s}     p  -j    Peripheral  (paresthesiae,   special 

1^  -  sense) 

h,   Urinary  symptoms. 

[  Inspection 
j    Facies 
3^ — General  Physical  J    Nutrition 
Differentials        ]    Glands 

j    Superficial  and 
[^  Deep  Reflexes 

[  Inspection 
I    Palpation    \  Pressure 
4 — Local  Physical    )    Percussion  f  pain 
Differentials      \   Auscultation 

I   Mensuration  |  Serous  Sangui- 

1^  Exploratory  Puncture  f   nous  Purulent 

5 — Laboratory  Differentials. 
A^   Sputum 

B,  Stomach 

r  FreeH.  CI.  (N.  =  yV^) 
(TZ,   Chemical  of  contents  \  Combined  H.  CI. 

(  Carbon  Compound  Acids, 

b.   Physical  of  contents — Color,  sediment,  odor,  etc. 

!Boas-Oppler 
Sarcinae 
Atypical  Cells 

[  X-ray   (with   Bismuth). 
I    K.  I.  in  capsules 
</,   Motor  Power  of  Stomach  \   Asparagin 

I    Measured    quantity   of 
1^  liquid 

C,  Blood 

a^   Leucocyte  Count,  Differential  Count 

Small  lymphocites,  20-30  ic 
Large  "  4-8^ 

(Normal)  -(    Polymorphonuclear  neutrophiles, 

I  62-70  io. 

[   Eosinophiles,  y^—^io 


40  SCHEME. 

b,   Hemoglobin  per  cent 

r,   Color  Index  (Hemoglobin  per  cent  divided  by  per 

cent  of  red  cells.      Normally  one.) 
d,   Parasites  (Malaria,  Spirillum,  Bacteria,  etc.) 
r,   Injection  into  animals 
y,   Widal  and  other  tests 

D,  Urine  in  addition  to  usual  tests 

Indican  (Intestinal  putrefaction) 
Cryoscopy  (In  renal  involvement) 

E,  Feces:    Undigested  Food,    Blood,   Ova,  Parasites,  Bac- 

teria. 

/%   Tissue  Section  and  Staining  Reactions 

6-,   Examination  of  Punct.  Fluid,  (  ^PJ^^^*?  Gravity. 
-c      A   ^      rr^  A   ,.  T^      {  Albumm 

Exudate,   Iransudate  or  Pus  )  p 

•G — Drug   DiFFERENriALS. 

Effect  of  K.  I.  Hg.,  Quinine,  etc. 

7 — Mechanical  Differentials. 

Effect  of  Rest,  Extension,  X-ray,  Hydrotherapy,  etc. 

^ — Exploratory  Incision. 

SUB-SCHEME    HI. 

To  answer  the  frequently  asked  question  "Causes  of." 
For  example  :  Causes  of  hemorrhage  ;  of  dyspnea;  of  vomit- 
ing, etc.  All  such  questions  are  answered  by  reference  to  the 
first  portion  of  Sub -Scheme  II,   viz. 

(T.I.D.)     TUMOR,  INJURY,  DISEASE  OR  MALFORMATION. 

If  the  question  is  so  framed  as  to  require  the  causes  of  a 
-lesion  of  one  of  the  hollow  viscera  T.  I.  D.  M.  should  be  applied, 
— within  the  lumen ;  to  the  wall  of  the  viscus,  and  to  the  region 
about  it.  It  will  thus  be  seen  that  by  applying  this  simple 
■scheme  to  such  question  as  the  causes  of  intestinal  obstruction, 
no  less  than  twelve  points  are  immediately  suggested  by  the 
■scheme  for  discussion. 


SCHEME  n 

Such  a  system  of  schemes  would  be  too  long  and  cumber- 
some for  practical  use  unless  abbreviated  and  adjusted  to  each 
subject,  and  in  recitation  work  it  is  not  intended  that  the  nega- 
tive, but  only  the  positive  and  most  important  factors  be  dwelt 
upon.  The  advantage  of  knowing  a  system  such  as  has  been 
given  is  that  if  called  upon  to  talk  on  any  given  subject  or  to 
write  about  it,  the  work  can  be  done  speedily,  fully  and  without 
liesitation.  In  the  pages  which  follow,  an  attempt  will  be  made 
to  pursue  in  general  the  outlines  suggested,  but  it  will  be  read- 
ily seen  that  they  cannot  advantageously  be  followed  in  full. 
It  may  be  well  before  going  on  to  a  general  consideration  of 
certain  surgical  questions,  to  illustrate  in  some  detail  the  mode 
of  application  of  these  schemes. 

Apply,  for  example,  the  general  scheme  to  such  a  disease 
as  erysipelas.  This  is  intended  to  be  used  if  a  general  descrip- 
tion of  erysipelas  be  asked  for.  If,  however,  the  subjective  or 
"general  symptoms  of  the  disease  be  desired,  apply  "Sub-Scheme 
I."  If  the  dififerential  diagnosis, — and  it  may  here  be  said  that 
in  any  case,  whenever  diagnosis  is  asked  for,  it  is  understood 
to  signify  differential  diagnosis, — apply  "Sub-Scheme  II." 

As  the  application  of  this  scheme  is  possibly  a  little  more 
■complicated  than  that  of  the  preceding,  it  may  not  be  amiss 
to  follow  it  out  in  detail. 

As  suggested,  the  phrase  "T.  I.  D."  with  an  M  added  to  it 
is  the  first  thing  to  think  of  for  differential  diagnosis. 

Tumor?  Negative.  Injury?  The  patient  may  or  may 
not  be  cognizant  of  having  been  injured.  Disease?  Onset 
■sudden  and  severe.     Malformation?     Negative. 

History  of  previous  injury?  May  or  may  not  be  negative. 
Of  previous  disease?     Often  affirmative. 

History  of  operation?     Positive  or  negative. 

Age  ?     More  common  in  early  adult  life. 

Sex?     Somewhat  more  common  in  the  male. 

Occupation?  More  common  in  those  exposed  to  trauma- 
tism. 

Social  State?     Negative. 

Pain?     Usually  not  marked.     "Stiff." 

Disability?     Present. 

Vomiting?     Often  a  prominent  symptom. 


12  SCHEME. 

]^)0\vcls?     Irregular. 

Jaundice?     Absent. 

T.  P.  R.  ?     105.  120,   24. 

Nervous  Symptoms?     Early  delirium. 

Glands?  Typical  involvement  of  glands  in  the  neighbor- 
hood, specially  true  of  facial  infection. 

Reflexes?     Negative. 

Inspection?     Swelling;  peculiar  color. 

Palpation?     Typical  harsh  feel. 

Sputum?     Negative. 

Stomach?     Negative. 

Blood?  Leucocyte  count  roughly  parallel  with  tempera- 
ture chart.      (Von-Limbeck). 

Differential  Count?  Marked  increase  in  polymorpho- 
nuclear cells. 

Hemoglobin  per  cent?     Negative. 

Color  Index?     Less  than  one. 

Parasites?  Bacteria  not  in  sufficient  numbers  to  be  read- 
ily seen. 

Injection?     Toxic  to  animals. 

Urine?  Free  amount  of  albumin  and  finely  granular  casts, 
if  far  enough  progressed. 

Indican?     Negative. 

Cryoscopy?     Negative,  except  in  presence  of  renal  disease. 

Feces?     Negative. 

Tissue  Section  ?  Bacteria  seen  crowding  the  lymphatic 
spaces. 

Such  a  scheme  as  this  is  of  necessity  cumbersome,  but  it 
afifords  the  only  known  means  of  covering  a  given  subject 
rapidly  without  omitting  any  important  details. 

It  will  clearly  be  seen  that  the  points  established  here  will 
serve  to  differentiate  this  disease  as  clearly  as  it  may  be  from 
any  disorder  with  which  one  might  confound  it. 

Throughout  these  notes,  the  terms  "Proximal"  and 
"Distal"  will  be  used,  the  heart  being  understood  to  be  the 
center. 


SCHEME  13 

In  less  detail  apply  this  scheme  for  differentials  to: — 

Non-impacted   Fracture   of  Dislocation  of  Femur. 

Neck  of  Femur.  (Dorsal) 

TUMOR. 

Moderate  fullness  in  Scarpa's  If  thin,  marked,  postero,   ex- 

triangle,  ternal. 

INJURY. 
Moderate  violence.  Great  violence. 

PREVIOUS  INJURY. 
Not  infrequent.  Absent. 

PREVIOUS  DISEASE. 

Some  form  of  rarifying  osti-  Absent, 

tis,  not  uncommon. 


AGE. 

Past  adult  life. 

Adult  life. 

SEX. 

Female. 

Male. 

OCCUPATION. 

Sedentary 

Hard  labor. 

PAIN.     . 

Great,  but  not  constant. 

Excruciating,  constant. 

DISABILITY. 

Typically     complete     unless  Complete, 
impacted. 

■      INSPECTION. 

Characteristic    attitude,     ex-  Flexion,     internal     rotation, 

tension  and  external  rota-  adduction. 

^^on.  Postero-external  swelling. 
Moderate  swelling  in  Scarjaa's 
.  triangle. 

PALPATION. 

Pain  increased  on   crowding  Pain  decreased  on  crowding 
extremity  upward.  extremity    upward.         In- 
Decreased  by  traction.    Mod-  creased  by  traction.      May 
erate  tenderness  in  Scarpa's  ^^  Crepitus, 
triangle.    May  be  Crepitus. 


14  SCHEME. 

MENSURATION. 
Fracture,  Nelaton's  Line.  Dislocation. 

Tip  of  great  tuberosity,  prox-  Relation  to  line,  not  constant, 

imal  to,  instead  of  upon  it. 

BRYANT'S  TRIANGLE. 

Negative  or  minus.  May   be    approximately  nor- 

mal.    Variable. 

TAPE   MEASURE. 

Shortening  from   ^4  to  3  in-  May  be  shortening  or  length- 

ches   A.  S.  vS.    to    internal  ening. 

maleolus. 

LABORATORY  FINDINGS. 
Obviously  negative  in  this  class  of  cases. 

Subjective  symptoms  are  frequently  asked  for.  It  must 
be  understood  in  the  use  of  the  schemes  that  that  one  is  in- 
tended to  be  utilized,  which  is  obviously  most  applicable  to 
the  disease  or  injury  under  consideration.  For  example,  as 
has  been  said  before,  the  general  scheme  is  indicated  chiefly 
in  the  Vv^ider  or  more  general  surgical  diseases,  although  there 
is  hardly  any  form  of  lesion  to  which  it  may  not  be  applied. 
In  the  case  of  more  localized  injuries,  as  for  example  fractures, 
the  scheme  must  necessarily  be  a  narrow  and  exact  one.  This 
is  further  considered  in  the  Chapter  on  Fractures. 

The  giving  of  subjective  symptoms  is  very  much  facilitated 
by  remembering  that  practically  all  surgical  lesions  present 
but  two  subjective  symptoms — rPain  and  Disability. 

Should  a  disease  presenting  such  multifarious  symptoms 
as,  for  example,  colelithiasis,  be  asked  for,  the  subjective  symp- 
toms are  easily  given  by  Sub-Scheme  I.  Disability  can  be 
understood  to  include  a  broad  variety  of  conditions, — almost 
anything  deviating  from  the  normal.  It  may  be  local  or  gen- 
eral, and  of  any  degree.  In  this  disease,  the  patient  will  not 
have  observed  anything  abnormal  in  !Mouth,  Pharynx  or 
Esophagus. 

Stomach  ?  This  is  typically  the  seat  of  pain  and  disability 
so  great  that  eminent  authorities  have  found  it  difficult  to  dif- 
ferentiate between  colelithiasis  and  carcinoma  of  the  pylorus. 


SCHEME.  iry. 

Small  and  great  gut?  There  is  no  pain  save  that  attending" 
habitual  constipation.  The  disability  results  in  clay  colored 
stools. 

Liver  or  other  glands?  Jaundice  depending  on  the  posi- 
tion of  the  stomach  and  other  factors.  Often  pain  at  Robson's. 
point. 

Lungs?     Foul  breath. 

Brain?     Headache  and  increasing  dyscerebration. 

Special  Senses?     Yellow  conjunctivae. 

Peripheral  Nerves?     Paresthesiae  frequent. 

Kidneys  and  G.  U.  ?     Bile  stained  urine. 

Extremities?     Progressive  disability. 


No  claim  for  special  excellence  or  for  any  originality  is; 
made  for  these  schemes.  They  have  been  printed  in  their 
present  form  on  the  conviction  that  what  has  worked  well  for 
one  series  of  men  will  work  well  for  another.  Individuals  will 
probably  be  able  to  modify  them  to  suit  their  needs  and  fancies, 
but  adherence  to  some  such  general  system  will  win  in  the 
future  as  it  has  in  the  past,  the  mvich  coveted  Appointments- 
in  the  New  York  Hospitals. 


CHAPTER    II. 

INFLAMMATION. 

\n  the  erection  of  any  building,  a  scaffolding  is  the  first 
consideration.  Even  if  the  work  be  simply  the  repair  of  an 
■existing  edifice,  this  scaffolding  must  begin  at  the  ground  and 
reach  to  the  break.     It  often  costs  more  than  the  repairs. 

Such  a  scaffolding  is  used  in  nature.  A  clear  grasp  of  this 
simple  proposition  makes  the  subject  of  inflammation,  gener- 
ally considered  a  great  bugbear  difficult  to  understand  and  un- 
interesting, a  very  simple  matter. 

The  subject  of  tissue  repair  is  by  no  means  intricate.  The 
process  naturally  depends,  as  in  the  case  of  a  building,  on  the 
degree  of  repairing  which  is  to  be  done.  The  red  cells  and 
the  plasma  are  the  bricks  and  mortar;  the  phagocytes  and 
nature's  other  agents  are  the  laborers. 

If  the  injury  to  the  parts  be  not  so  severe  as  to  have  act- 
ually destroyed  cellular  life,  the  scaffold  erection  naturally 
does  not  take  place.  Consider  the  familiar  case  of  a  weal  on 
the  back  of  a  horse.  It  rises  soon  after  the  horse  is  struck 
with  the  lash.  AVhat  happens?  Something  very  easy  to 
understand.  There  is  a  disturbance  of  the  vaso-motor  nerves. 
The  small  vessels  along  the  line  of  the  traumatism  immedi- 
ately dilate  ;  as  a  natural  consequence,  the  current  slows.  The 
leucocytes,  presenting  a  greater  degree  of  resistence  from  their 
larger  size  and  coarser  texture,  naturally  lag  behind  and  are 
arranged  around  the  outside  of  the  stream  against  the  vessel 
wall.  Following  their  instinct,  they  immediately  begin  to  emi- 
grate through  the  chinks  of  the  endothelial  lining. 

Fig.  1. 


Figure  showing  emigration  of  leucocytes. 


SIMPLE  EXUDATIVE  INFLAMMATION.  17 

Coincidental  with  this  the  fluid  part  of  the  blood  leaks  out 
into  the  intercellular  spaces.  If  the  blow  has  been  a  hard  one, 
a  certain  number  of  red  cells  will  pass  out  in  a  manner  some- 
what similar  to  that  described  for  the  white  cells.  This  pro- 
cess is  called  diapedesis.  In  most  cases  of  moderate  injury, 
probably  a  few  of  these  erythrocytes  escape  from  the  vessels. 

This  process,  in  the  case  of  the  horse  under  consideration, 
continues  at  so  rapid  a  rate,  that  a  local  swelling  is  produced. 
This  is  because  the  exudate,  as  the  materials  which  pass  out 
are  called,  cannot  be  diffused  into  the  neighboring  tissues  as 
rapidly  as  they  are  extruded.  It  requires  only  common  sense 
to  see  that  as  this  process  continues,  the  characteristic  weal 
will  form.  After  the  recovery  of  the  vaso-motor  nerves,  a 
balance  is  gradually  established  between  the  rate  of  exudation, 
— the  vessels  gradually  assuming  their  normal  tone, — and  the 
absorption  of  the  exudate  into  neighboring  uninjured  vessels. 
The  establishment  of  this  balance  marks  a  cessation  in  the 
growth  of  the  weal  and  immediately  thereafter,  the  ridge  be- 
gins to  be  absorbed.  Any  one,  who  has  had  anything  to  do 
with  horses,  knows  that  this  may  take  twelve,  twenty-four  or 
even  more  hours  before  its  completion. 

In  this  case  there  has  been  no  need  of  ascaffolding,  for  the 
only  moderately  injured  tissues  have  returned  entirely  to  nor- 
mal. The  process  which  has  been  here  portrayed  has  been 
named  Simple  Exudative  Inflammation. 

This  simple  exudative  inflammation  will  be  found  to  be 
the  direct  cause  of  the  symptoms  of  many  of  the  minor  sick- 
nesses, both  medical  and  surgical.  Whether  it  attacks  the 
mucous  membranes,  as  is  evidenced  by  a  cold  in  the  head,  an 
inflammation  of  the  uterus  or  of  the  gut ;  whether  it  occurs 
in  connective  tissue,  in  the  muscles,  or  in  any  of  the  hard  or 
soft  parts  of  the  body,  the  process  is  always  the  same,  a  sim- 
ple affair  easy  to  understand. 

However,  the  organism  is  not  always  so  fortunate  as  to 
have  its  cells  live  after  the  primary  injury,  and  it  may  there- 
fore become  necessary  for  it  to  replace  those  which  have  been 
lost.  It  is  not  meant  by  this  that  the  organism  is  always  able 
to  replace  the  special  cells  which  were  lost  if  they  belong  to  a 
very  specialized  type,  but  connective  tissue  cells,  at  any  rate, 


18  (iRANULAR  CHANGE. 

arc  created  to  repair  tlie  loss  of  continuity  and  prevent  the 
danger  of  infection. 

Now  suppose  a  case  in  which  the  injury  has  been  sufficient- 
ly severe  and  of  such  nature  as  to  have  admitted  pus  produc- 
ing germs  to  the  part.  It  is  wise  to  remember  that  almost  any 
germs  with  the  exception  of  a  few  such  as  the  tetanus  bacillus 
and  the  diphtheria  bacterium,  which  remain  localized,  can 
all  produce  pus.  Now,  if  some  of  these  germs,  either  in  pure 
culture  or  in  mixed,  are  introduced  into  this  wound  of  graver 
character  which  we  are  considering,  the  tissues  have,  in  addi- 
tion to  the  primary  mjury,  to  fight  against  the  poisonous 
toxins  which  are  created  by  the  germs.  They  are  simply  the 
products  of  the  life  of  these  organisms,  but  they  produce  when 
in  small  quantity  what  is  known  as  Cloudy  Swelling, — a  con- 
dition in  which  the  protoplasm  of  the  cell  is  seen  under  the 
microscope  to  be  granular  and  the  nucleus  to  have  become  in- 
distinct— and  when  in  large  quantities,  early  death  of  the  cell. 

Undoubtedly,  in  a  great  many  cases  which  grossly  appear 
to  be  simple  exudative  inflammation,  as  in  the  case  of  a  weal 
before  referred  to,  there  are  a  moderate  number  of  cells  which 
undergo  this  cloudy  swelling.  It  is  to  be  understood  that 
this  condition  gives  rise  to  no  marked  symptom  by  which  it 
may  be  recognized  clinically.  The  cells,  which  have  under- 
gone this  granular  change,  either  return  to  their  normal  con- 
dition in  the  course  of  a  few  days,  or  else  they  die.  If  they  die, 
they  disintegrate,  and  the  particles  are  removed  by  the  phago- 
cytes and  by  the  circulatmg  plasma.  This  process  takes  place 
slowly  and  gives  no  gross  external  evidence. 

Suppose  the  double  trauma  of  injury  and  poison  to  have 
been  so  great  that  the  cells,  not  only  underwent  granular 
change,  but  actually  died.  What  then  takes  place?  Death 
occurs  not  only  in  the  cells  of  the  inflamed  connective  tissue, 
but  also  in  any  parenchymatous  cells  which  may  be  in  the 
neighborhood.  The  eatire  mass  becomes  saturated  with  the 
body  fluids.  It  is  "Walled  Off"  by  nature  from  the  living 
parts  and  an  eiTort  is  made  by  the  organism  to  extrude  it. 

This  is  the  type  of  the  process  which  takes  place  when  a 
stitch  abscess  forms,  or  an  ordinary  boil  develops.  The  so- 
called  core  of  the  boil   is   the   mass  of  dead  lymphatics  and 


PRODUCTIVE  INFLAMMATION.  19 

Other  vessels,  nerves,  muscular  and  other  tissues,  together  with 
the  blood  elements  which  extrude  into  the  tissues,  as  before 
described,  immediately  after  the  beginning  of  the  injury.  In 
the  case  of  the  boil,  the  traumatism  is  either  absent  or  in- 
significant as  compared  with  the  infection.  This  core,  so 
familiar  to  all,  is  removed,  and  the  parts  are  then  in  position 
to  begin  to  heal.  Now  it  is  that  the  scafifolding  is  erected. 
It  consists  of  a  reticulum  or  net  work  of  fibrin,  whica  fills  the 
whole  part  as  though  a  spider  had  woven  a  web  in  every  di- 
rection within  the  cavity.  Leucocytes  and  erythrocytes  swarm 
along  the  strands  of  this  network  and  become  entangled  in  its 
meshes.  The  process  of  creation  of  what  is  known  as  scar 
tissue  is  technically  called  Productive  Inflammation.  It  will 
be  noted  that  whereas  the  changes  referred  to  in  exudative 
inflammation  have  affected  the  vessels  only,  those  in  produc- 
tive inflammation  have  to  do  particularly  with  the  changes 
in  the  cells  of  the  aftected  part. 

Productive  Inflammation  may  or  may  not  be  accompanied 
by  an  appreciable  degree  of  exudative  inflammation.  In  any 
reconstructive  process,  there  is  probably  always  a  certain 
amount  of  exudation  taking  place.  Nevertheless,  it  is  cer- 
tain that  there  are  types  of  productive  inflammation  which  are 
to  be  seen  at  certain  periods  in  the  healing  of  granulating 
wounds  in  which  the  fluid  is  taken  up  by  the  parts  just  as  rap- 
idly as  it  is  extruded.  This  may  be  called  dry  productive  in- 
flammation, as  contrasted  to  the  combined  or  wet  form.  The 
typical  example,  however,  of  dry  productive  inflammation  is 
to  be  seen  in  the  so-called  sclerotic  changes  of  the  arteries  and 
the  cirrhoses  of  the  liver,  kidneys  and  other  organs. 

The  boil  under  consideration  has  reached  the  condition 
in  which  the  scaffolding  has  been  erected  and  the  laborers 
with  their  bricks  and  mortar  are  aloft.  It  is  obviously  not  pos- 
sible for  them  to  recreate  the  intricate  arrangement  of  the 
tissues  as  it  existed  prior  to  the  toxemic  injury.  What  they 
proceed  to  do,  therefore,  is  to  make  granulation  tissue,  which 
in  course  of  time  turns  white,  and  is  known  as  a  Scar. 

How  is  this  done?  A  great  deal  is  heard  now-a-days  about 
abscesses  being  "walled   ofif."     This  term   is  used  every  day 


20  CHEMOTAXIS. 

in  speaking  of  appendicitis.  What  is  the  wall  and  where  does 
it  come  from? 

By  a  process  which  has  been  called  Chemotaxis,  white 
cells  from  far  and  near  have  been  called  into  the  neighbor- 
hood of  the  injury.  They  arrange  themselves  in  the  form  of 
■a  hollow  sphere  about  the  dead  part  and  after  assuming  the 
function  of  thus  protecting  the  general  body  from  invasion, 
they  are  called  instead  of  leucocytes,  phagocytes  from  the 
Greek  phagein — to  eat.  From  having  been  simple  white  cells, 
they  become,  by  a  process  of  conscription,  or  chemotaxis,  the 
eating  or  defending  cells. 

Nowhere  can  the  process  about  to  be  described  be  seen 
more  beautifully  than  in  one  of  the  small  tubercles  so  frequent- 
ly observed  in  the  muscular  tissue  of  the  diaphragm.  These 
tubercles  may  for  the  purposes  of  description  be  regarded  as 
miniature  boils,  and  as  the  whole  tubercle  may  be  seen  under 
one  field  of  the  microscope,  which  is  not  the  case  with  a  boil, 
the  process  of  "walling  ofif"  may  be  conveniently  and  accur- 
ately studied  in  it.  What  is  true  of  the  wee  tubercle  is  equally 
true  of  the  large  boil,  and  what  is  true  of  the  boil  is  true  of 
the  appendicular  or  pyemic  abscess  containing  a  pint  to  a 
quart  of  pus.  The  point  is  to  understand  that  this  process  is 
the  same  for  all  like  conditions  irrespective  of  their  size  or 
position.  So  in  the  great  abscess,  the  tubercle  or  the  boil,  this 
hollow  spherical  layer  of  protecting  white  cells  masses  itself 
between  the  well  tissues  on  the  one  hand  and  the  dead  on  the 
other, — between  the  sterile  body  on  the  one  side  and  the  in- 
fected wound  on  the  other.  Between  the  phagocytes  there  is 
some  fibrin.  This  is  what  is  meant  by  "walling  off."  There 
are  other  elements  in  the  "wall"  as  will  be  seen  later,  but  this 
"Round  Cell  Zone"  is  all-important. 

The  next  element  to  consider  in  the  process  of  dry  produc- 
tive inflammatory  regeneration  are  the  so-called  Fibroblasts. 
Whether  they  are  derived  from  pre-existing  connective  cells, 
or  whether  they  spring  from  certain  of  the  white  cells,  is  not 
definitely  known,  but  the  practical  point  is  that  coincidental 
with  the  establishment  of  the  zone  of  white  cells,  already  de- 
scribed, there  is  laid  down  between  the  dead  part  and  the  outer 
wall  of  leucocytes,  a  secondary  wall  of  these  fibroblasts.    These 


HOW  TO  KNOW  A  FIBROBLAST.  21 

are  to  strengthen  the  "wall."     A  convenient  way  to  remember 
about  these  fibroblasts  is  to  ask  the  question: 

How  does  a  fibroblast  differ  from  a  woman  ?  The  answer 
is  that  the  fibroblast  is  fat  when  it's  young  and  thin  when  it's 
old,  whereas  a  woman  is  thin  when  she's  young,  and  fat  when 
she's  old. 

This  is  a  homely  and  perhaps  ungallant  means  of  stating 
the  life  history  of  the  fibroblast.  By  mutual  pressure,  and  by 
pressure  derived  from  the  outside  shell  of  phagocytes;  called 
"Round  Cell  Inflammatory  Zone,"— the  fibroblasts  assume  first 
a  hexagonal  form  and  are  finally  pressed  out  into  the  familiar 
ribbons  characteristic  of  fibrous  tissue.  A  good  illustration 
to  show  how  this  process  begins  may  be  seen  in  the  Giant's 
Causeway  at  the  North  of  Ireland,  where  by  mutual  pressure 
columns  many  feet  in  length  have  been  formed,  each  and  every 
one  being  hexagonal.  Drops  of  mercury,  when  allowed  to 
press  upon  each  other,  will  also  become  hexagonal  before  they 
are  confluent. 

As  the  young  fat  fibroblast  gradually  elongates,  its  nucleus 
becomes  more  and  more  indistinct  until  it  is  finally  lost.  Be- 
fore this  takes  place,  however,  the  cell  accomplishes  the  pur- 
pose for  which  it  was  in  part  designed,  viz. — the  deposition 
of  intercellular  material.  This  aids  largely  in  the  formation 
of  the  fibrous  tissue. 

Starting  with  a  comparatively  small  number  of  these 
young  fibroblasts,  it  is  necessary  that  they  should  be  multiplied 
as  rapidly  as  possible.  This  is  accomplished  in  part  by  emigra- 
tion, just  as  among  people  in  a  new  territory;  in  part  by  re- 
production. This  takes  place  by  the  process  formerly  known 
as  karyokinesis,  but  now  commonly  called  mytosis.  The  great 
care  of  nature  in  splitting  the  nucleus  so  that  it  shall  be  ac- 
curately divided  between  the  two  new  cells  shows  what  an 
important  function  it  plays  in  human  life. 

The  fibroblasts  are  now  increasing  at  a  rapid  rate  and  are 
beginning  to  be  crowded  into  the  fibrinous  reticulum.  It  must 
not  be  lost  sight  of  that  this  net  work  is  a  well  defined  definite 
visible  mass,  spongy  to  the  touch  and  red  to  the  eye,  because 
of  included  red  blood  cells.  The  whole  structure  is  shortly  to 
be  swept  away.     How  is  this  accomplished?     Before  nature 


22  CAPILLARY  FORMATION. 

attempts  it,  she  makes  sure  that  the  permanent  structure 
destined  to  take  its  place  is .  well  established.  This  cannot 
be  done  without  providing  food  and  nourishment  for  the 
new  cells  to  live  upon.  How  is  this  brought  there?  When 
the  sphere  of  fibroblasts  is  only  one  or  two  cells  thick,  they 
can  readily  be  fed  by  the  transudation  to  them  of  life  giving 
plasma,  but  there  is  a  limit  to  the  distance  to  which  this  food 
can  percolate  between  the  cells,  and  it  becomes  necessary  to 
establish  channels  to  carry  it  toward  the  interior  of  the  struc- 
ture. 

Capillary  Formation  begins  by  a  head  to  tail  union  of 
a  series  of  specialized  connective  tissue  cells.  The  walls  at 
the  point  of  juncture  break  down,  their  included  protoplasm 
guided  by  unknown  forces,  begins  to  circulate,  and  what  was 
a  simple  series  of  end  to  end  cells,  has  become  a  tunnel 
through  which  blood  soon  begins  to  flow. 

These  Capillary  "Tufts"  are  by  a  marvellous  provision 
constructed  in  a  loop  so  that  they  start  and  end  in  the  liv- 
ing parts.  If  they  coursed  straight  away  into  the  new  terri- 
tory, they  would  obviously  soon  become  blockaded.  Through 
their  delicate  endothelial  walls  along  the  whole  course  of  the 
new  vessel,  but  more  particularly  at  the  turn  of  the  loop  which 
is  nearest  the  dead  part,  the  plasma  with  its  cell  feeding  ele- 
ments streams,  and  the  products  of  metabolic  cellular  life  are 
in  like  manner  returned. 

It  will  often  have  been  noticed  how  closely  this  micro- 
scopic picture  conforms  to  the  clinical  findings  when  granula- 
tion tissue  is  treated.  Such  tissue  frequently  has  to  be  cur- 
retted.  This  can  be  done  without  pain  to  the  patient,  because 
there  are  no  nerves  in  the  part.  The  hemorrhage,  however, 
is  always  very  brisk.  This  is  because  the  tissue,  as  already 
described,  is  largely  made  up  of  young  capillaries. 

At  about  this  time,  supposing  a  large  number  of  successive 
spherical,  walls  of  endothelial  cells  to  have  arranged  them- 
selves, like  the  many  skins  of  an  onion,  about  the  scaffolding 
which  had  filled  in  the  site  of  the  extruded  dead  tissue,  nature 
begins  to  realize  that  in  the  region  of  capillary  development 
the  scaffolding  is  no  longer  necessary.  The  builders,  which 
were  instrumental  in   creating  the  new  and  permanent  wall, 


WET  PRODUCTIVE  INFLAMMATION.  23 

are  now  obliged  to  see  to  their  own  removal  and  to  the  destruc- 
tion of  the  net  work  which  supported  them.  As  is  often  the 
case  with  people,  they  are  "turned  down"  by  those  whom  they 
have  helped. 

How  does  this  process  of  removal  of  the  scaffolding  take 
place?  The  phagocytes,  which  it  has  at  length  been  decided, 
are  able  to  destroy  living  cells  as  well  as  dead,  now  turn  their 
attention  from  quarreling  with  the  invading  horde  of  bacteria 
to  carrying  away  the  slowly  disintegrating  net  work  of  fibrin. 
Many  of  these  remarkable  white  cells  have  themselves  died, 
either  in  conflict  with  the  bacteria,  or  because  of  a  failure  of 
their  food  supply.  The  commissary  department  is  as  neces- 
sary to  them  as  it  is  to  soldiers  in  the  field.  When  dead,  it  be- 
comes incumbent  upon  living  phagocytes  to  carry  them  into 
the  blood  stream  or  to  extrude  them  through  the  surface. 

Thus  it  is  seen  that  these  dead  leucocytes,  which  had,  when 
called  upon  to  do  so,  assumed  a  phagocytic  function,  enter 
largely  into  the  formation  of  v^fhat  is  called  Pus. 

The  white  cells,  the  dead  bacteria,  the  devitalized  and 
toxin  charged  plasma,  together  with  broken  masses  of  tissue, 
basement  substance  and  other  refuse  are  carried  away  either 
by  the  plasma  stream  or  by  the  remaining  leucocytes. 

This  process  continues  until  the  primary  structure  which 
was  laid  down  immediately  after  the  infliction  of  the  injury 
is  entirely  removed  and  its  place  taken  by  the  permanent  tis- 
sue. This  permanent  tissue  does  not  resemble  the  original 
tissue  which  was  destroyed.  When  it  has  filled  the  wound 
and  granulation  is  said  to  be  complete,  the  region  looks  red 
and  is  only  partially  enervated.  As.  time  goes  on,  nerves,  the 
most  delicate  structure  in  the  human  body,  are  gradually 
formed,  so  that  sensation  returns  in  part  or  in  whole.  The 
fibroblasts  as  they  grow  older  and  following  the  inverse  of  a 
woman's  career,  grow  thinner  and  thinner;  they  have  an  in- 
herent tendency  to  contract.  This  shrinkage  of  the  granula- 
tion tissue  is  of  vital  importance  in  plastic  surgery.  Without 
it,  the  scars  of  wounds  would  always  be  red.  Because  of  it, 
in  from  six  months  to  a  year,  the  capillaries  are  squeezed  so 
that  they  no  longer  carry  a  similar  volume  of  blood  and  the 
part  turns  white. 


24  DRY  PRODUCTIVE  INFLAMMATION. 

Such  is  the  general  history  of  the  course  of  Wet  Produc- 
tive Inflammation. 

Dry  Productive  Inflammation,  it  has  been  said,  is  seen 
typically  in  sclerosed  arteries,  in  the  well  known  "hob-nailed" 
liver  and  in  contracted  kidneys.  This  process,  so  insidious 
in  its  development  and  so  fatal  to  life,  is  known  to  be  un- 
accompanied by  the  production  of  pus,  but  its  "dryness,"  or 
freedom  from  the  products  of  accompanying  exudative  in- 
flammation is  probably  as  already  stated  more  or  less  relative. 
It  is  convenient,  however,  for  the  purposes  of  classification, 
to  look  upon  the  process  as  a  dry  one. 

In  point  of  time,  dry  productive  inflammation  is  infinitely 
slower  than  the  wet.  As  is  well  known,  it  takes  years  for  a 
liver  to  become  cirrhotic  or  for  arteries  to  sclerose,  but  the 
processes  although  differing  much  in  time,  are  identical  in 
the  means  of  their  execution.  While  one  capillary  tuft  is  be- 
ing formed  in  the  dry  type,  a  hundred  are  created,  utilized  and 
pinched  out  of  existence  in  the  wet.  The  one  is  a  chronic 
process  and  the  other  is  acute,  but  save  for  the  presence  of 
moisture  in  the  one  and  its  relative  absence  in  the  other,  of 
slowness  in  the  one,  and  of  speed  in  the  other,  these  so-called 
"types"  are  indistinguishable. 


SUMMARY  OF  CHAPTER  II. 

(i)  Inflammation,  if  looked  at  from  a  practical  common 
sense  standpoint  and  if  shorn  of  the  enormous  amount  of 
detail  with  which  it  is  usually  surrotmded,  is  a  very  simple 
process  quite  easy  to  understand.  The  most  common  form  of 
inflammation  is  called  Simple  Exudative  Inflammation.  This 
has  nothing  to  do  with  the  formation  of  new  cells,  and  is 
characterized  only  by  changes  in  the  vessels.  This  form  of 
inflammation  gives  rise  to  the  familiar  symptoms  of  many 
every  day  diseases  such  as  colds  and  the  like.  It  may,  or 
may  not  be  accompanied  by  granular  change,  or  so-called 
"Cloudy  Swelling,"  and  there  may,  or  may  not  be,  slight 
destruction  of  cells.  Cell  death  is  frequently  absent  from  this 
form  of  inflammatory  change. 


SUMMARY  OF  INFLAMMATION.  25. 

(2)  Productive  Inflammation.  This  is  not  to  be  looked 
upon  as  a  separate  and  distinct  phenomenon  apart  from  ex- 
udative inflammation.  It  is  as  a  rule  a  continuation;  a  ter- 
mination of  the  exudative  process.  It  may  be  for  conveni- 
ence divided  into  the  "Dry"  and  the  "Wet,"  these  groupings 
being  made  in  accordance  with  the  degree  to  which  it  is 
accompanied  by  the  exudative  change.  Productive  inflam- 
mation has  to  do  not  with  the  vessels,  as  in  the  case  of  the 
exudative  form,  but  with  the  cells.  It  produces  fibrous  scar 
from  granulation  tissue.  The  "^dry"  form  is  chronic  and  is 
accompanied  typically  by  no  dilation  of  the  vessels.  This  form, 
it  is,  which  is  instrumental  in  producing  the  various  cirrhotic 
and  sclerotic  changes,  often  called  disease. 

(3)  "Walled  Off."  This  term,  which  is  now  so  frequent- 
ly used,  can  be  properly  understood  only  as  interpreted  from 
its  inflammatory  relations.  The  "wall"  is  first  round  cells 
and  fibrin — later  fibroblasts  and  fibrous  tissue.  It  is  a  typical 
product  of  Productive  Inflammation. 

(4)  As  the  vessels  are  the  important  factors  in  exudative 
inflammation,  so  are  the  fibroblasts  and  other  cells  in  produc- 
tive inflammation. 

(5)  The  so-called  "phagocyte"'  is  nothing  more  than  a 
leucocyte  which  has  been  brought  to  the  scene  of  the  injury 
by  a  conscriptive  process  called  Chemotaxis.  They  are  capa- 
ble of  destroying  bacterial  life,  but  their  most  important  func- 
tion is  to  remove  the  solid  products  of  inflammation,  which 
when  diluted  form  pus. 

(6)  One  of  the  easiest  means  of  understanding  the  pro- 
cess of  productive  inflammation  is  to  look  upon  the  primary 
deposit  in  the  part  killed  as  a  temporary  scaffolding  which  is. 
to  be  removed  by  nature's  processes  as  the  permanent  cells. 
take  their  position.  An  excellent  illustration  of  the  applica- 
tion of  this  stage  of  productive  inflammation  for  the  uses  of 
surgery  lies  in  its  employment  in  operations  where  a  portion 
of  the  tissue  is  removed  and  the  sealed  cavity  allowed  to  fill 
with  blood  clot.  This,  as  will  be  found  later,  is  customarily, 
referred  to  as  "healing  under  Schede's  moist  blood  clot." 

(7)  The  various  processes  of  the  inflammatory  condition, 
although  they  are  recognizedly  diverse  and  in  spite  of  the  fact 


26        EXTENT  OF  INFLAMMATORY  PROCESS. 

that  they  extend  over  very  wide  fields,  viz. — those  in  w^hich 
the  injury  is  inflicted,  and  those  upon  which  its  recovery  takes 
place,  must  be  recognized  as  part  and  parcel  of  one  contin- 
uous interrupted  process.  Whoever  looks  upon  them  as  sepa- 
rate cannot  possibly  clearly  understand  them.  Furthermore, 
inflammation  once  clearly  understood,  constitutes  by  all  odds 
the  most  important  stepping  stone  to  a  basic  interpretation 
of  the  science  and  art  of  surgery.  It  must  be  remembered 
that  not  a  solitary  lesion  exists  which  is  unaccompanied  -by 
■one  or  other,  or  all  of  the  forms  of  the  inflammatory  process 
-here  described. 


CHAPTER  III. 

THE  ARTERIES  AND  THE  VEINS. 

This  chapter  may  be  well  introduced  by  a  sketch  showing 
the  smallest,  the  least  known  and  the  most  frequently  asked 
triangle  in  the  body. 

Fig.  2. 


ANEURISM. 

This  is  the  most  important  surgical  disease  of  the  arteries. 
It  will  not  be  amiss  to  apply  the  scheme  from -Chapter  I  in  this 
interesting  lesion. 

Definition, — An  aneurism  is  a  pulsating  swelling,  filled 
with  blood  and  communicating  with  an  artery. 

Etiology, — The  predisposing  causes. 

Age?     Period  of  active  life. 

Sex?     Male  more  liable. 

Color?     Said  to  be  more  common  in  the  negro. 


28  PATHOLOGY  OF  ANEURISM. 

Occupation  ?  Hard  labor.  Traumatic  aneurism  was  four 
times  more  common  after  the  Civil  War  than  it  is  to-day. 

Exciting  Causes?  Spontaneous  aneurisms  may  be  due  to 
congenital  defects  or  to  the  toxins  of  a  hypothetical  germ 
(syphilis).  Traumatic  aneurisms,  usually  seen  on  the  extremi- 
ties and  not  infrequently  in  the  popliteal  space,  are  the  direct 
result  of  trauma.  Popliteal  aneurisms  are  commonly  said  to 
be  of  frequent  occurrence  in  grooms  and  liveried  footmen  who 
are  obliged  to  dress  in  very  tight  pants  and  stand  for  hours 
at  a  time  with  the  popliteal  artery  on  the  stretch  from  bend- 
ing their  knees  backward.  This  is  an  excellent  illustration  of 
an  occupation  disease.  Fig.  3,  shows  the  surgical  relations  of 
the  popliteal  space  and  emphasizes  the  depth  at  which  the 
artery  lies. 

Pathology, — Aneurisms  result  from  the  stretching  of  weak 
areas  in  a  vessel  wall.  The  gross  pathology  varies  according 
to  the  type  of  aneurism.  Spontaneous  aneurisms  are  usually 
in  the  chest  or  abdomen,  those  occurring  in  the  first  situation 
being  typically  saccular  whereas  those  found  in  the  abdominal 
regions,  particularly  in  the  aorta,  are  generally  elongate,  or, 
as  it  is  called,  "Fusiform."  A  great  many  sub-divisions  of  the 
gross  pathology  of  aneurisms  have  been  made.  One  of  these 
is  the  rare  "Circoid"  aneurism.  In  this  the  aneurism  does  not 
communicate  with  the  artery  but  the  entire  vessel  becomes 
aneurismal.  It  has  therefore  been  defined  as  a  "uniform  dila- 
tation of  an  artery  and  all  its  branches."  It  is,  in  other  words, 
a  varicose  artery. 

Classifications  of  aneurisms  have  been  based  upon  the 
shape  of  the  sac;  upon  the  method  of  infliction  of  the  injury 
causing  the  aneurism,  etc.,  but  for  practical  purposes  it  is  neces- 
sary simply  to  remember  that  they  may  be  saccular,  cylindrical, 
dissecting,  spontaneous  or  traumatic. 

Minute  Pathology, — This  deals  with  the  condition  of  the 
vessel  wall  at  the  site  of  injury  and  with  the  character  of  the 
contained  clot.  Occasionally  the  blood  current  splits  an  inner 
wall  of  the  vessel,  separating  the  coats  and  an  aneurism  results 
from  the  stretching  of  the  outer  wall.  This  forms  a  so-called 
dissecting  aneurism.  If  all  the  coats  of  the  vessel  are  not  in- 
cluded in  the  sac  wall  it  is  known  as  a  false  aneurism.     True 


SYMPTOMATOLOGY  OF  ANEURISM.  29 

Aneruisms  on  the  contrary  have  all  three  vessel  coats  in  the 
sac  wall. 

Symptomatology, — The  detailed  subjective  symptoms  of 
aneurism  are  of  importance  chiefly  to  the  internist,  for  aneur- 
isms which  lend  themselves  to  surgical  intervention,  or  as  they 
have  been  called  "Surgical  Aneurisms"  present  little  beyond 
the  two  characteristic  surgical  subjective  symptoms  of  pain 
and  disability.  Medical  aneurisms,  as  those  which  must  at 
present  be  relegated  to  the  internist  have  aptly  been  called, 
present  a  very  characteristic  and  intricate  chain  of  symptoms, 
which,  it  is  not  in  the  province  of  this  book  to  discuss.  An 
interesting  one,  for  example,  is  the  dilatation  and  subsequent 
contraction  of  the  pupil  in  thoracic  aneurism. 

The  objective  symptoms  of  surgical  aneurism : — 

Inspection, — A  pulsating  swelling  seen  in  the  course  of 
an  artery.  - 

Palpation.     Expansile  pulsation. 

Percussion.     Flat. 

Auscultation.     Occasionally  'a  "bruit." 

Differential  Diagnosis.  Again  excluding  the  medical 
aneurisms,  the  question  of  differential  diagnosis  depends  natur- 
ally on  the  position  of  the  swelling.  Let  it  be  supposed  that 
a  swelling  has  appeared  spontaneously  in  the  popliteal  space 
of  an  old  syphilitic  soldier.  It  might  be  a  gumma;  it  might 
be  an  osteosarcoma;  it  might  be  a  bursa  from  one  of  the 
numerous  tendons  in  the  neighborhood ;  it  might  be  an  aneur- 
ism. 


l/ks^us  Zi(f. 


fVerirc 


T»r7*-fcar?  Ve/g^ 


Oui^cT     A/cat/' 


Fig.  3 


The  relations  and,  particularly  the  depth  of  the  popliteal  artery,  are  shown 
in  this  figure.     Note  origin  and  course  of  external  popliteal  nerve. 


DIFFERENTIAL. 


31; 


Gumma. 


Sarcoma, 


Bursa. 


Ankurism. 


History  of  Tumor. 


Slow  growth. 


Absent. 


Evidence  of  syph- 
ilis elsewhere. 
Onset  slow. 


Absent. 


Chancre. 


Adolesence. 


Rapid  growth. 


Often  present  (as 
fracture] . 


Probably  slow. 

Injury. 

Absent. 


Disease. 


Cachexia.      Onset 
rapid. 


Absent.      Onset 
slow. 


Often  present. 
(Some  form  of 
chronic  irrit't'n) 


Previous  Injury. 

May  be  present. 


Negative. 


Previous  Disease. 
May  be  metastatic  Absent. 

Ace. 
Childhood.  Early  middle  age. 

Occupation. 

Continuous    over- 
Negative.         .  workofone 
muscle. 


If  present,  not  se- 
vere. 


Pain. 

Always      present,   -j,^         . 
often  intense.  ^' 

Disability. 

Not  marked.  Marked.  Moderate. 


Growth  moderate- 
ly rapid,  but  on- 
set acute. 


May  be  absent  or 
present. 


Arterio  -  sclerosis 
frequent.  Onset 
rapid. 


Typically  present, 
either  acute  or 
chronic. 


Arterio  -  sclerosis, 
endocarditis,  al- 
coholism, syphilis. 


Adult. 


Heavy  work. 


Sometimes  v  e  r  y- 
severe. 


Marked. 


32 


DIFFERENTIAL.— Continued. 


Gumma. 


Sarcoma. 


Bursa. 


Aneurism. 


Nervous  Symptoms. 
(Central.) 


■Often    marked , 
particularly 
night  headache. 


Often  marked. 


Negative. 


Occasional. 


Negative. 


Paresthesiae. 


Absent. 


GENERAL  PHYSICAL. 

Facies. 


Pale  and  anxious. 


Disordered. 


•General     discrete 
enlargerrient. 


Cachectic. 


Negative. 


Nutrition. 


Much   disordered. 


Negative. 


No  local  enlarge 
ment  unless  in 
fected. 


Glands. 

Negative. 


May  be  absent. 


Negative. 


REFLEXES. 
Deep. 

Negative. 


LOCAL  PHYSICAL. 
Inspection. 


Red  swelling. 


Cool.      May    pul- 
sate (heave). 


Darker  red. 


Normal  color. 


If  present,  due  to 
sclerosis. 


Occasional. 


Drawn. 


Negative. 


Negative. 


Negative- 


Palpation. 

Hot.     May  crepi-  Cold.       May  pul- 
tate  and  pulsate       sate  (heave). 


Normal  color. 


Hot.     Expansible 
pulsation. 


DIFFERENTIAL.— Continued. 


33 


Gumma. 


Sarcoma. 


Bursa. 


Aneurism. 


Auscultation. 


Negative. 


Possible  bruit. 


Negative. 


LABORATORY  FINDINGS. 

Tissue  Section. 


Characteristie. 


Characteristic. 


Negative. 


COMPLICATIONS. 

Immediate. 


Negative. 


Moderate  increase 


Softening. 


Life:    Negative, 
K.I.  improves. 


K.I.  or  mixed. 


Often     pressure 
pain. 


Fracture,     Metas- 
tasis and  death. 


Typical  bruit. 


Negative. 


Negative. 

Mediate. 

Negative. 

Remote. 

Disability. 

PROGNOSIS. 
Immediate. 


Almost  surely  fa-l  ^'l^  negative, 
^„i  ^         I      tuuction     ques- 


tal. 


tionable. 


TREATMENT. 


Disarticulation  at 
hip. 


Excision  of  sac. 


Gangrene  or  rup- 
ture. 


Disability. 


Disability.      Loss 
of  extremity. 


May  be  fatal, func- 
tion impaired. 


Mata's  operation  if 
possible. 


Undoubtedly  much  more  might  be  said  in  attempting  to 
give  the  differential  diagnosis  between  these  hypothetical  cases, 
but  it  is  not  claimed  that  this  differential  is  complete  in  all  de- 
tails.    Further  application  of  the  scheme  will  supply  these  if 


34 


CERVICAL  ANASTOMOSIS. 


desired.  As  with  Darwin's  article  on  earth  worms,  very  little, 
will  remain  to  be  said  after  the  scheme  has  been  thoroughly 
applied.  Earth  worms  have  been  observed  for  the  last  thirty 
years,  but  nothing  new  has  been  added  to  the  observations  of 
the  famous  naturalist. 


[jtl  Car<J-^"i 


O  i^/'t-r/ie.ia  ? 


Fig.  4. 
Cervical  Anastomosis. 


LIGATION. 


35 


Word  schemes,  however,  are  not  the  only  ones  which  lend 
themselves  favorably  to  a  discussion  of  the  arteries.  Fig.  4. 
shows  an  invaluable  diagrammatic  scheme  of  the  difficult  and 
too-often  asked  cervical  anastomosis.  It  is  not  artistic  but  im- 
mensely useful.  One  of  the  important  differences  between 
medicine  arid  surgery  is  that  medicine  is  given  over  very  largely 
to  diagnosis,  whereas  surgery  is  concerned  more  particularly,  or 
at  least  to  as  great  an  extent,  with  treatment.  An  eminent 
authority  has  said  perhaps  not  too  wisely,  but  certainly  concise- 
ly, that  in  general  the  medical  treatment  of  a  given  condition 
can  be  summed  up  in  three  words :  Nurse,  Feed  and  Stimulate. 
This  is  obviously  an  exaggeration  if  applied  too  widely,  but  it 
serves  to  emphasize  an  important  point. 

As  a  result  of  this  essential  difference  between  medicine 
and  surgery,  and  partly  because  of  the  trend  of  the  times, 
which  is  to  leave  medical  cases  more  to  themselves  than  was 
the  custom  until  recently,  it  has  been  noted  that  particularly  in 
the  matter  of  aneurisms,  the  surgical  treatment  has  always 
come  in  for  a  wide  share  of  attention. 

Until  a  couple  of  years  ago,  very  little  change  had  been 
made.  It  was  regarded  as  settled  that  no  improvement  could 
be  looked  for  in  the  time  honored  methods  of  ligation  or  of 
extirpation.     The  classical  procedures  will  be  presented  first 

and  then  the  modern  method  of 
Matas.  It  is  always  a  disagree- 
able chore,  but  one  which  has  be- 
come a  sort  of  classical  entity,  to 
learn  the  names  of  the  surgeons 
who  devised  various  methods, 
good,  bad  and  indifferent,  for  the 
treatment  of  aneurism.  It  is  al- 
most impossible  to  hold  these  with- 
out the  aid  of  visual  memory,  and 
they  can  be  conveniently  kept  in 
the  mind's  eye  by  learning  to  diaw 
the  accompanying  sketch : 


{ftl^TrLL^i 


^■%-  p/tf;?a.yr,i/.f 


S/ilSSOl 


Wf^RDllOf 


■36  MEDICAL   TREATMENT. 

Dawbarn  has  used  a  similar  one  in  his  lectures  for  many  years. 
Hunter,  it  will  be  observed,  tied  proximally,  one  or  more 
branches  being  given  off  between  the  position  of  the  ligature 
and  the  aneurismal  sac.  Anel  (like  the  German  word  meaning 
ass)  tied  in  the  soft  and  friable  tissue  too  near  the  aneurism. 

Brasdor  was  as  unfortunate  in  the  choice  of  his  position 
as  was  Anel,  although  there  is  no  German  word  to  commemor- 
ate his  failure.  In  our  own  Bowery  vernacular,  however,  he 
may  be  said  to  have  had  an  over  abundance  of  '^brass"  to  expect 
•a  ligature  placed  as  he  placed  it,  to  do  any  good. 

Antyllus,  although  he  lived  long  before  the  two  preceding 
gentlemen,  was  sufficiently  courageous  and  intuitive  to  combine 
their  methods,  except  that  he  went  further  and  removed  the  sac. 

Phyllagrius,  the  old  Greek,  boldly  opened  the  sac,  as  shown 
by  the  X  in  the  diagram. 

Wardrop  placed  his  ligature  in  exactly  the  inverse  position 
of  Hunter's.     It  was  no  good,  and  therefore  "dropped  off." 

The  above  mnemonics  albeit  inelegant  have  been  found 
useful. 

All  medical  aneurisms  and  those  of  a  surgical  nature  un- 
der certain  conditions,  are  subjected  to  medical  treatment. 
For  aneurism,  this  is  summed  up  in  four  words ;  instead  of  the 
three  which  usually  cover  it.  They  are  Rest,  Starve,  Purge 
and  K.  I.  This  is  known  as  Tuffnell's  Treatment.  He  was  a 
sagacious  Irish  surgeon  who  hoped  to  dry  the  patient  so  that 
his  blood  would  coagulate  in  the  sac. 

There  are  several  other  methods  which  are  only  occasion- 
ally used.  Perhaps  the  most  important  of  these, — important 
because  the  changing  fancy  of  surgical  fashion  appears  to  be 
bringing  it  into  prominence  once  more,  is  compression  by 
digetal  pressure. 

Shepherd,  of  Montreal,  has  recently  advocated  the  re- 
introduction  of  this  method,  although  he  admits  that  with  the 
modern  methods  of  aspetic  technic,  there  is  no  very  strong 
ground  in  favor  of  it.  It  is  a  sort  of  relay  race,  ten  minutes 
being  the  limit  of  time  which  any  one  hand  can  hold  a  large 
artery. 

Tuffnell's  treatment  failing,  efforts  have  been  made  in  the 
case  of  certain  inoperable  aneurisms  to  increase  the  thickness 


MATA'S  OPERATION.  37 

of  the  sac  wall  by  causing  the  blood  to  clot  upon  it  by  local 
treatment.  Of  course,  Tuffnell's  treatment  aims  at  increasing 
the  coagulability  of  the  blood  by  simply  drying  it  up.  The 
patient  is  desiccated  and  starved  so  that  the  heart  becomes 
weak  and  the  blood  current  very  much  diminished  in  force 
and  rate.     Slowing  the  pump  also  favors  clot  formation. 

Recently  another  means  of  increasing  the  coagulability  of 
the  blood  which  has  been  used  in  aneurisms,  and  particularly 
in  pancreatitis,  is  the  exhibition  of  immense  doses  of  calcium- 
chloride;  from  30  to  50  grains  being  given  three  or  four  times 
a  day. 

All  these  efforts  failing,  bodies  have  been  introduced  into 
the  sac  upon  which  the  fibrin  could  be  whipped  out  as  the  blood 
rushed  through  it.  The  sac  has  been  needled ;  it  has  been 
treated  with  electricity ;  it  has  been  filled  with  hundreds  of  feet 
of  watch  spring  steel ;  it  has  had  crowded  into  it  many  yards 
of  fine  malleable  wire.  The  supposed  difference  between  these 
two  materials  is  that  the  spring  coils  itself  upon  the  periphery 
of  the  sac  as  it  is  fed  in,  whereas  the  malleable  wire  makes  a 
net  work  in  every  possible  direction  back  and  forth  across  the 
diameter  of  the  sac,  not  being  confined  to  the  wall. 

The  danger  of  these  local  methods  of  treatment  is  self 
evident.  There  is  no  means  of  safe-guarding  against  tearing 
loose  and  freeing  into  the  blood  stream  particles  of  clot  which, 
swept  away  to  the  lungs,  cause  pulmonary  embolism  and 
speedy  death ;  to  the  brain,  death,  hemiplegia  or  other  lesions ; 
to  the  spleen,  kidneys  or  other  organs ;  infarcts  and  various 
degenerative  processes.  These  local  methods  of  attacking  the 
aneurism  consequently  are  indicated  only  when  its  site  renders 
it  absolutely  inoperable ;  when  all  methods  of  cure  by  concen- 
tration and  slowing  of  the  blood  stream  have  failed  ;  when  the 
patients  life  is  despaired  of. 

Matas'  Operation,  This  technic  is  being  very  generally 
introduced  for  the  treatment  of  surgical  aneurisms,  and  will 
probably  soon  be  adopted  to  cure  certain  medical  aneurisms 
which  are  now  practically  hopeless.  Very  favorable  reports 
are  being  made  upon  it.  It  represents  by  far  the  most  im- 
portant advance  which  has  been  made  in  the  surgical  treatment 
of  aneurism  since  the  introduction  of  asepsis. 


38  PHLEBITIS. 

Preservation  of  the  Lumen  of  the  Artery  is  the  object  of 
the  technic.  For  admirable  details  and  illustrations  of  the 
operation,  reference  is  best  made  to  Brewer's  Manual.  The 
technic,  in  general,  consists  in  the  application  of  plastic  sur- 
gery to  the  sac,  by  which  means  it  is  obliterated  and  the  open- 
ing between  it  and  the  artery  is  closed.  The  lumen  of  the 
artery  is  preserved.  Obviously  it  is  the  ideal  method.  When 
it  was  first  advocated  by  its  creative  author,  objection  was 
made  to  it  upon  the  ground  that  the  extensive  endarteritic 
changes,  which  in  the  nature  of  the  lesion,  must  always  be 
present, — often  to  the  extent  of  depositing  solid  plaques  of 
limestone — would  in  most  cases  prevent  its  employment.  Th^ 
"proof  of  the  pudding,  however,  is  in  the  eating,"  and  the  sug- 
gestion, although  apparently  based  on  sound  mechanical  rea- 
soning, seems  happily  to  have  lacked  confirmation.  It  even  ap- 
pears possible  that  this  method  as  already  suggested  may  soon 
enable  surgeons  to  invade  the  territory  of  the  medical  man 
and  .take  from  him  the  treatment  of  many  abdominal  and 
thoracic  aneurisms.  (See  "Surgical  Treatment  of  Abdominal 
Aneurism,"  by  C.  B.  Maunsell,  British  Medical  Journal,  June 
1 8,  1904). 

Large  arteries  are  often  cut  accidentally.  Brewer  has  de- 
monstrated experimentally  (Surgical  Laboratory,  Columbia), 
that  such  wounds  may  be  closed  and  the  lumen  of  the  vessel 
preserved.  After  stopping  the  blood  flow  and  thoroughly  dry- 
ing the  part  he  winds  the  artery  with  a  thin  extremely  adherent 
elastic  bandage. 

PHLEBITIS. 

This  is  one  of  the  most  interesting  conditions  in  surgery. 
Its  sequelae  are  formidable ;  its  etiology  in  many  cases  is  entire- 
ly unknown. 

It  is  a  disorder  to  which  the  schemes  of  Chapter  I,  can 
most  advantageously  be  applied.  As  before  stated,  there  is  not 
room  to  carry  this  out  in  a  small  book,  but  the  point  to  be  made 
is  that  by  conscientiously  following  the  scheme  any  one,  after 
a  little  reading,  can  write  or  say  all  that  is  known  on  the  sub- 
ject of  phlebitis.  The  point  to  be  striven  for  here  as  every- 
where else,  is  such  a  thorough  acquaintance  with  the  scheme 


PHLEBITIS.  3y 

that  it  naturally  revolves  in  the  brain  like  a  rotary  sifter,  pick- 
ing out  all  the  points  bearing  upon  the  subject  matter  and  ex- 
cluding everything  extraneous  to  it.  Obviously,  it  is  a  ques- 
tion of  time  and  patience  to  attain  this  end. 

What  are  the  important  points  in  phlebitis  which  naturally 
suggest  themselves  as  the  scheme  is  perused? 

Definition.  An  inflammation  of  a  vein,  due  either  to  the 
toxins  of  germs,  or  to  unknown  spontaneous  causes. 

Etiology.  Femoral  phlebitis  in  particular,  often  follows 
aseptic  and  successful  laparotomies*  Usually  on  the  left  side. 
Believed  by  Keen  to  be  caused  by  mechanical  pressure  on  the 
left  common  iliac  vein. 

Pathology.  Gross.  If  septic,  full  of  decomposing  blood 
clot.  If  sterile,  vessel  dilated  and  clot  may  be  incomplete. 
Adinute.     If  septic  crowded  with  the  specific  germ. 

Symptomatology.  General.  If  septic,  evidences  of  sep- 
ticemia.    Local.     If  septic,  blue  line,  rat-tail  feel. 

Differential  Diagnosis  usually  to  be  made  between  the  two 
varieties. 

Complications.  If  septic  ;  those  of  septicaemia.  Swelling 
of  extremities. 

Prognosis.     If  septic,  may  cause  death.     In  any  case  often 
impairs  function  of  extremity  for  a  long  period. 
Treatment.     Medical,  nurse,  feed,  stimulate. 
Surgical.      Palliative;    mild    case;   elevate,   rest,    ice   bag, 
elastic  bandage.     Radical ;  severe  case,  septic,  excise  and  drain. 
In  this  particular  case  the  sub-schemes  for  giving  subjec- 
tive symptoms  and  differential  diagnosis  are  seen  under  ordin- 
ary conditions  not  to  be  necessary,  but  thej  may  be  applied  to 
phlebitis  as  to  anything  else,  if  it  be  so  desired. 

Summary  of  Phlebitis.  It  may  be  septic  or  aseptic,  the 
latter  form  being  one  of  the  most  dreaded  sequels  of  aseptic 
laparotomies.  It  is  on  a  par  with  pulmonary  embolism  in  this 
respect,  for  it  steals  in  after  the  door  has  apparently  been 
closed.  Like  varicocele,  this  form  is  usually  on  the  left  side, 
and  as  in  the  case  with  varicocele,  is  probably  due  to  the 
mechanics  of  the  anatomical  structure.  The  septic  form  is  oc- 
casionally a  sequel  of  operations;  but  may  follow  any  dirty 
wound.     It  is  common  in  the  internal  jugular,  that  vein  having 


40  GRAVITATION  DISEASES. 

been  infected  through  contiguity  of  the  lateral  sinus  to  a  germ 
laden  mastoid,  or  by  continuity  with  the  facial  vein.  (See  Fig. 
13) 

VARICOSE  VEINS. 

These  interesting  lesions  are  the  bread  winners  of  the 
3'oung  surgeon.  They  cause  an  immense  amount  of  human 
suffering.  Their  etiology  is  simple.  Shaler  has  said,  that  as 
in  the  case  of  hernia  ;  of  all  the  displacements  of  the  uterus  and 
ovaries,  and  a  host  of  similar  lesions,  varicosities  arise  from 
man's  getting  too  ambitious  and  rearing  up  on  his  hind  legs  to 
walk.  This  class  of  lesions,  from  which  the  animals  are  prac- 
tically immune,  could  well  be  classified  mider  the  general  term 
"Gravitation  Diseases." 

The  three  most  important  varicosities  occur  in  the  leg, 
in  the  pampiniform  plexus  of  the  spermatic  cord ;  where  they 
are  familiarly  known  as  varicocele,  and  in  the  inferior  and 
middle  hemorrhoidal  plexuses,  where  they  are  called  hemorr- 
hoids. 

Practically  these  are  self-evident,  and  except  in  the  case 
of  varicocele,  rarely  have  to  be  differentiated.  Their  treat- 
ment consequently  is  of  first  importance.  In  the  legs,  this  de- 
pends somewhat  upon  the  type.  Suppose  a  diffuse  varicosity 
to  exist  all  below  the  knee  giving  that  red,  nasty,  swollen, 
boggy  leg>  so  characteristic  of  the  "hobo"  and  of  the  worn  out 
cook.  As  Jacobi  says:  "What  to  do?"  Make  a  boot  of  the 
patient's  own  skin  by  cutting  a  circle  around  the  leg,  just  dis- 
tal to  the  knee.  Avoid  the  important  cutaneous  nerves  and 
cut  to  the  muscles.  Tie  the  vessels  as  you  cut,  and  on  com- 
pleting the  section,  suture  the  skin.  This  is  called  "Schede's 
operation."  It  blocks  every  cutaneous  vessel  and  forces  the 
circulation  into  the  deep  veins. 

If  the  lesion  be  characterized  by  swelling  of  the  distal  por- 
tion of  the  long  saphenous  and  with  dilatation  and  tortuosity 
of  the  vessel  in  the  upper  part  of  its  course,  the  tortuosities  may 
be  excised  and  the  upper  segment  treated  by  subcutaneous 
ligation  or  by  removal  of  small  sections  along  the  course  of  the 
vein.  For  treatment  of  proximal  long  saphenous  varicosity. 
Fowler  has  devised  a  unique  method.     He  ligates  at  a  chosen 


TREATMENT  OF  VARICOCELE.  41 

point  six  odd  inches  distal  to  the  saphenous  opening  and  again 
ligates  between  the  opening  and  the  first  ligature.  At  this 
point  he  cuts  the  vein  and  frees  it  enough  to  grasp  it  with  a  wet 
towel.  He  then,  by  a  sudden  jerk,  pulls  the  severed  section 
of  the  vein,  hook,  line,  bob  and  sinker,  clean  out  of  the  tissues. 

Every  one  must  remember  the  pictures  in  school  text 
books  of  physics  which  show  Torricelli's  famous  experiment 
in  which  he  burst  a  tremendously  powerful  cask  by  screwing 
a  pipe  into  it  and  pouring  w^ater  in  at  the  top  of  the  pipe.  By 
this  means  and  without  a  very  high  pipe,  such  a  cask  can  be 
blown  to  pieces.  No  wonder  the  veins  dilate,  for  in  getting  up 
upon  our  hind  legs,  we  illustrate  admirably  the  Torricellian 
principle. 

Varicocele.  This  lesion  has  until  recently  been  treated  to 
a  large  extent  by  subcutaneous  ligation.  It  is  recounted  of 
a  famous  French  surgeon,  that  on  one  occasion  a  patient  called 
at  his  office  and  the  surgeon  found  him  to  be  suffering  from  a 
bi-lateral  varicocele.  Esculapius  was  about  to  go  to  the  opera, 
but  hastily  taking  his  needle, after  injecting  a  little  cocaine,  he- 
threw  a  ligature  about  the  parts  on  both  sides.  The  varicocele 
promptly  disappeared,  but  in  six  months  time  the  testicles  had 
atrophied !  On  discovering  this,  the  patient  bought  a  revolver, 
went  to  the  office  of  the  surgeon  and  shot  him  dead.  He  was 
arrested,  tried  and  promptly  discharged  by  a  court  on  the. 
ground  of  "justifiable  insanity!" 

Accidents  similar  to  this  have  combined  to  put  a  quietus 
on  sub-cutaneous  ligation  for  varicocele.  It  is  contrary  to  the 
spirit  of  surgery  to  work  in  the  dark. 

The  open  operation  here  as  elsewhere  is  to  be  preferred. 
Most  surgeons  advocate  placing  the  incision  as  high  as  possible 
so  as  to  avoid  cutting  the  tissue  of  the  scrotum  which  is  most 
difficult  to  sterilize.  The  important  points  are  to  note  the 
vas  deferens  by  its  rat-tail  like  feel ;  to  remember  that  the  three 
arteries  are  so  small  that  their  pulsation  can  hardly  be  felt;  to- 
note  that  the  offending  veins  are  usually  separate  and  distinct 
from  the  normal  veins  of  the  vas ;  to  tie  above  and  below ;  to- 
excise  the  included  inch  or  more  of  the  plexus  and  to  make 
an  internal  suspensory  by  approximating  the  cut  butts  together. 

Hemorrhoids.     The  easiest  way  to  treat  these  varicosities 


42  TREATMENT  OF  HEMORRHOIDS. 

efficac  ously  is  to  put  an  angiotribe  on  them  for  a  few  minutes. 
This  instrument  is  a  giant  forceps  designed  to  exercise  a  pres- 
sure of  from  one  to  2,000  pounds  to  the  square  inch.  The  tis- 
sues embraced  in  its  jaws  are  compressed  to  the  thinness  of  the 
finest  sheet  of  tissue  paper.  This  treatment  is  particularly 
suitable  for  the  single  external  hemorrhoid,  for  it  can  be  done 
very  conveniently  under  local  anesthesia. 

Many  people  dread  a  general  anesthetic  more  than  they 
do  an  operation.  For  severe  cases  of  internal  hemorrhoids, 
the  suggestion  by  Tinker  that  the  entire  perineal  region  may 
be  completely  anesthetized  by  using  massive  infiltration  of  a 
half  per  cent,  of  eucaine  in  the  neighborhood  of  the  great 
ischiatic  tuberosity  where  the  internal  pudic  and  long  pudendial 
nerves  course  about  the  bone  will  be  of  importance  in  further- 
ing the  treatment  of  these  cases.  If  prostrates  can  be  painless- 
ly enucleated  by  this  method,  surely  hemorrhoids  may  be 
similarly  treated.      (See  illustration  under  Prostatectomy.) 

The  clamp  and  cautery  is  probably  the  favorite  method  of 
treating  hemorrhoids. 

Another  widely  employed  technic  is  to  seize  the  apex  of 
the  tumor  with  a  blunt  clamp,  to  circumscribe  its  base  with  a 
sharp  knife  through  the  mucous  membrane,  to  transfix  it  with 
a  needle  bearing  heavy  pedicle  silk;  to  cast  a  Staffordshire  knot 
•over  the  growth,  to  tie  it  so  tightly  as  if  possible,  to  kill  the 
nerve  endings,  and  finally  to  cut  ofif  the  apex  as  near  to  the 
suture  as  is  safe.     This  is  known  as  ligation. 

In  the  execution  of  this  technic,  the  flaw  is  apt  to  lie  in 
the  fact  that  it  is  almost  impossible  to  tie  the  suture  tight 
enough  to  kill  the  nerves.  If  these  live,  for  several  days  after 
the  operation,  the  surgeon  had  better  leave  the  patient  exclu- 
sively to  the  nurse,  for  the  pain  makes  the  remedy  worse  than 
the  disease.  Injecting  the  veins  with  irritants  and  escharotics, 
■such  as  equal  parts  of  tincture  iodine,  glycerine  and  phenol, 
is  widely  practiced  by  quacks  and  constitutes,  in  the  hands  of 
some  of  these  men  a  useful,  although  admittedly  dangerous 
palliative  treatment. 

The  Medical  treatment  of  hemorrhoids  is  satisfactorily  em- 
braced by  the  four  words,  nurse,   feed,   stimulate   and  bidet. 

Fig.  6,  shows  the  veins  of  the  face  and  neck.     They  are 


NEVI. 


43 


frequently  asked  for  in  hospital  examinations.  The  temporo- 
maxillary  sinus,  when  varicose,  constitutes  a  very  evil  lesion, 
its  removal  being  extremely  difficult. 


wTT  juqu/ar 

*■  fi^t  a„tCTSst 


Fig.   6 


Nevi.  These  dilatations  occupy  a  mid -position  between 
the  arteries  and  the  veins,  by  virtue  of  their  occurring  either, 
in  the  small  continuations  of  these  vessels,  or  else  actually  in 
the  capillaries  which  connect  them.  They  have  been  con- 
veniently divided  into  capillary  and  cavernous.  The  capillary 
form  is  best  known  in  the  familiar  "mother's  mark."  All 
'^'mother's  marks"  are,  however,  not  due  to  capillary  dilatations, 
some  being  caused  by  pigmentary  deposits.  These  dilatations 
are  usually  treated  in  one  of  two  ways.  They  are  either 
excised,  and  the  part  is  skin  grafted,  or  else  they  are  subjected 


44  VENOUS  ANASTOMOSIS. 

to  electrolysis.  The  negative  needle  of  a  galvanic  battery  is 
run  longitudinally  its  full  length  into  the  growth.  The  elec- 
trolytic action  destroys  a  number  of  cells  in  the  near  region  of 
the  puncture.  Productive  inflammatory  changes  take  place, 
and  as  explained  in  Chapter  II,  the  gap  is  presently  filled  with 
granulation  tissue.  At  no  distant  time  this  contracts,  and, 
clinically,  where  once  was  a  disfiguring  red  blotch,  will  be 
seen  a  fine  white  line.  A  multiplication  and  an  irregular  cross- 
ing of  these  fine  white  lines  eventually  destroy  the  growth, 
enough  capillaries  being  left  to  preserve  the  normal  skin  color. 
The  technic  is  tedious  to  the  operator  and  expensive  to  the 
patient. 

Cavernous  Nevi  are  lesions  which  sometimes  threaten  life. 
They  have  an  evil  habit  of  growing  with  such  rapidity  that 
they  may  be  difficult  to  differentiate  from  a  rapidly  growing 
sarcoma.  They  occasionally  yield,  when  inoperable  by  the 
knife,  to  prolonged  treatment  by  electrolysis.  Bubbles  of  hy- 
drogen can  in  these  cases  be  seen,  when  the  electrical  action  is 
going  on  satisfactorily  and  when  the  needle  is  suitablv  placed, 
coursing  at  the  rate  of  one  or  two  to  the  second  '♦through  the 
dilated  and  about  to  be  destroyed  veins. 

Wyeth  has  recently  devised  a  characteristically  ingenious 
and  simple  method  for  the  treatment  of  these  growths.  It 
consists  in  the  introduction  of  boiling  water  directly  into  the 
tissues,  the  water  being  boiled  by  a  lamp  held  under  a  syringe 
which  holds  half  a  pint  to  a  pint.  This  process  is  much  more 
rapid  than  electrolysis,  and  it  is  safe  if  care  be  taken  not  to 
introduce  enough  boiling  water  to  cause  necrosis.  In  other 
words,  not  more  tissue  should  be  destroyed  at  a  time  than 
can  be  taken  care  of  by  the  phagocytes  and  the  plasma,  without 
the  necessity  of  the  organisms  pushing  the  devitalized  ma- 
terial out  through  the  surface. 

The  knowledge  of  the  paths  by  which  the  blood  may 
return  when  the  portal  system  is  obstructed  is  an  important 
aid  in  establishing  many  diagnosis.  It  is  a  frequent  hospital 
question  and  is  therefore  given.      (From  Gray) 

(i)  By  anastomosis  of  mesenteric  veins  with  superficial 
abdominal. 

(2)  Of  phrenic  and  gastric  veins  with  those  of  Glisson's 
capsule. 

(3)  Of  superior  hemorrhoidal,  inferior  mesenteric  and 
internal  iliac. 

(4)  Gastric  and  esophageal  with  azygos  minor. 

(5)  Left  renal  and  intestinal. 


CHAPTER  IV. 


NERVES,  MUSCLES,  TENDONS  AND  BURSAE. 


Fig.   7. 


LUMBAR  PLEXUS. 


Hif't"'^ 


From  upper  four  Lumbar 
Nerves. 

The  1st  Lumbar  splits  into 
two;  the  2d,  3d  and  4th  split 
into  four  each. 

The  2nd  division  of  L, 
and  the  1st  of  the  II.  unite. 
(Genito-crural) 

The  2d  division  of  II.,  and 
1st  of  III.  unite.  (External 
cutaneous) 

The  3d  division  of  II,  and 
2d  division  of  3d,  and  1st  di- 
vision of  IV.  unite.  (Ant. 
crural) 

The  4th  division  of  II.,  the 
3d  division  of  III.  and  2nd 
of  IV.  unite.     (Obturator) 

The  4th  division    of    III., 
and  3rd  division  of  IV.  unite. 
(Accessory  obturator) 
The  4th  of  the  IV.  unite  with  V.      (Lumbo  Sacral  Cord) 
The  Mnemonic  for  this  is : 

"If  I  get  examined,  all's  over.      Oh!" 

The  two  most  interesting  problems  in  the  surgery  of 
nerves  are  suture  and  transplantation. 

According  to  very  recent  views,  the  outlook  on  suturing 
a  nerve  many  months  after  its  section,  is  almost  as  good  as  if 
the  operation  had  been  done  immediately  after  the  infliction 


46  NERVE  SUTURE. 

of  the  injury.  This  is  not  in  accordance  with  the  older  teach- 
ing, which  was  that  there  is  very  little  use  in  attempting  to  do 
anything  with  a  severed  nerve,  unless  it  can  be  operated  on 
immediately  after  being  cut.  This  recently  demonstrated  abil- 
ity of  the  nerve  to  re-establish  its  function,  even  if  united  long 
after  the  reception  of  the  primary  injury,  seems  to  show  that 
the  much  dreaded  degeneration  is  not  so  grave  as  was  formerly 
supposed  and  suggests  that  function  returns  in  some  other  way 
than  by  the  actual  re-establishment  of  the  axis  cylinders.  The 
conclusion  from  these  recent  observations  is  that  no  case  of 
peripheral  nerve  injury  should  be  refused  operation  simply  be- 
cause the  opportunity  to  unite  the  divided  ends  comes  at  a 
late  hour.  In  any  event,  whenever  the  union  is  made  and 
whatever  the  process  of  repair,  return  of  function,  which  may 
be  either  incomplete  or  complete,  comes  at  best  only  after 
months  of  patient  treatment  with  electricity,  massage  and 
hydrotherapy;  one  and  all. 

Another  conclusion,  which  is  of  very  great  importance  is 
this,  viz. — no  attempt  should  be  made  to  unite  the  ends  of  a 
divided  nerve  in  case  the  wound  is  known  to  be  dirty.  Inas- 
much as  a  moderate  delay  or  even  a  prolonged  delay  appears 
not  to  have  the  profound  importance  which  was  formerly  as- 
cribed to  it,  some  surgeons  now  advocate  postponing  the 
operation  until  after  the  active  manifestations  of  the  inflamma- 
tory reaction  have  cleared  away. 

The  attempt  to  replace  a  destroyed  segment  of  human 
nerve  by  grafting  an  equal  length  of  animal  nerve  has  failed. 
So  it  did  in  the  case  of  bone  grafting.  The  body  does  not  take 
kindly  to  any  form  of  graft,  except  skin  graft !  Decalcified 
bone  tunnels,  and  a  host  of  similar  devices,  the  supposed  pur- 
pose of  which  is  to  keep  the  pathway  open  for  the  axis  cylinders 
to  grow  along,  have  also  proved  failures.  They  should  proba- 
bly therefore,  be  entirely  abandoned  and  recourse  had,  in  the 
event  of  destruction  of  a  segment  of  the  nerve,  to  bone  resec- 
tion. This  of  course  applies  only  to  wounds  of  nerves  on  ex- 
tremities, and  although  in  the  arm  it  shortens  the  "reach,"  this 
is  justifiable  except  of  course  among  a  certain  class  of  athletic 
gentlemen. 

Transplantation  has  lately  awakened  a  widespread  interest, 


NERVE  TRANSPLANTATION.  47 

because  it  appears  that  the  possibilities  before  it  are  as  yet  only 
half  surmised.  As  has  often  happened  before,  supposed  ad- 
vantages of  this  technic  may  have  been  exaggerated. 

The  present  status  of  transplantation,  however,  is  such 
that  a  thorough  knowledge  of  how  the  technic  is  applied ;  its 
indications,  and  its  limitations  is  desirable.  So  far,  the  most 
important  application  of  the  principle  has  been  made  in  cases 
of  paralysis  of  the  seventh.  The  process  is  a  simple  one. 
Given  a  case  of  facial  palsy,  what  can  be  done  for  it?  Ob- 
viously it  can  be  massaged,  electrefied  and  hydrotherapized, 
but  as  is  well  known,  if  the  disturbance  be  centrally  situated 
absolutely  no  good  will  follow.  Until  very  recently,  it  was 
held  that  the  centres  of  the  cranial  nerves  differed  widely  from 
each  other.  They  certainly  send  out  impulses  having  utterly 
dififerent  characteristics.  The  medullary  centers  have  become- 
peculiarly  specialized,  in  that  for  example,  one  interprets  hear- 
ing, while  another  almost  adjacent  to  it,  controls  the  muscles: 
of  the  tongue.  The  one  is  a  higher  class  of  work  than  the 
other.  How  can  it  by  any  possibility  be  that  one  of  these 
little  bunches  of  cells,  after  a  short  education,  can  assume  the 
functions  of  the  other?  Whatever  be  the  answer,  the  fact  re- 
mains that  if  a  portion  of  the  hypoglossal  nerve,  as  it  courses, 
in  the  neck  toward  the  tongue,  be  grafted  into  a  centrally 
paralyzed  seventh  nerve,  the  patient  v>^ill,  under  favorable  con-. 
ditions,  regain  facial  control.  When  first  done,  it  was  not  ex- 
pected that  anything  would  happen.  As  is  sometimes  the 
case,  however,  the  unexpected  did  happen  and  the  control  of 
the  muscles  of  the  face  was  assumed  by  the  center  of  the 
twelfth.  This  center  did  its  own  work  and  that  of  the  seventh 
as  well.  What  an  interesting  series  of  possibilities  this 
awakens.  It  is  true  that  both  these  centers  have  to  do  primar- 
ily, with  the  creation  of  motor  impulses,  but  if  such  a  switchings 
of  motor  centers  is  possible,  may  it  not  untimately  lead  to  a 
swi-tching  of  the  special  sense  centres  as  well?  Will,  for  ex- 
ample, the  first  nerve  ever  be  made  to  assume  the  functions  of 
the  second,  thus  giving  sight  to  the  blind? 

MUSCLES. 

A  straiii  is  an  injury  produced  by  over-stretching  a  muscle., 
A  sprain  is  also  an  injury  produced  by  over-stretching  a  mus- 


48  CONTRACTURES. 

cle.  Each  of  these  may  occur  in  the  ligaments.  The  first 
may  be  said  to  be  disting-uishable  only  with  a  microscope,  or 
perhaps  not  even  by  such  delicate  means,  whereas  the  second 
is  always  accompanied  by  a  macroscopic,  or  physical  tearing 
'of  the  fibres.  Strains  are  more  apt  to  occur  in  muscles  than 
sprains,  which  are  usually  seen  in  the  neighborhood  of  joints, 
the  ligaments  being  torn. 

Muscles  are  apt  to  undergo  calcification.  It  is  well  to 
note  that  this  change  differs  from  ossification.  The  one  is  a 
dead  process,  the  other  a  living.  Ossification,  while  not  so 
common  as  calcification  in  the  muscles,  is  not  by  any  means 
unknown.  Rider's  bone  is  a  plate  forming  in  the  adduct  or 
longus  and  is  frequent  among  the  cavalry  men.  Drill 
bone  occurring  in  the  deltoid  muscles  is  occasionally  seen 
among  infantry- men.  These  lesions  are  the  result  of  chronic 
irritation  and  are  grouped  under  the  general  term  of  occupation 
diseases. 

Muscular  Contractures  are  of  great  interest  and  impor- 
tance. Their  treatment  forms  a  large  portion  of  the  work  of 
the  orthopedic  surgeon.-  They  are  of  two  distinct  types,  spas- 
modic or  relaxing  and  non-relaxing.  Spasmodic  contractures 
are  often  called  contractions. 

The  most  practical  way  to  dififerentiate  contractures  is 
to  give  the  patient  chloroform.  The  first  type  is  seen  typically 
in  those  cases  where  Nature  endeavors  to  make  splints  out  of 
the  organism's  muscles,  as  for  example,  to  protect  a  joint  in- 
flamed with  disease  from  harmful  motion.  The  rigidity  of  such 
muscles  is  so  great  and  the  tone  of  the  tension  so  constant 
that  it  is  often  impossible,  except  under  an  anesthetic^  to  tell 
whether  such  a  stiffness  is  of  the  transitory  or  permanent  type. 
Naturally,  if  transitory,  when  the  element  of  pain,  which  symp- 
tom calls  this  muscular  tone  into  action,  is  obliterated,  the  mus- 
cle relaxes,  and  the  condition  is  seen  to  be  spasmodic.  Muscles 
in  a  state  of  chronic  tonicity  are  apt  to  become  permanently 
shortened.  If  no  relaxation  occurs  a  non-relaxing  contraction 
is  demonstrated. 

Myotomy  or  Muscle  Section  is  indicated  in  non-relaxing 
contractures.  Familiar  examples  are,  section  of  the  sterno- 
mastoid  for  spastic  torticollis,  or  of  the  flexors  and  adductors 
in  late  stages  of  coxitis.  Tenotomy  usually  takes  the  place  of 
myotomy. 

The  fasciae  are  very  liable  to  degenerative  changes.  As 
elsewhere  in  the  body,  so  in  the  fasciae  fibrous  tissue  tends  on 
slight  provocation  to  become  very  thickened,  or  sclerosed,  as 
it  is  called.  It  will  be  remembered  that  this  process  has  been 
described  in  Chapter  II,  as  dry  productive  inflammation. 


DUPUYTREN'S  CONTRACTURE.  49 


Cc 


T-/r^//s 


Fig.  8 

One  of  the  most  interesting,  as  well  as  most  common,  con- 
tractures of  fasciae,  is  what  is  called  Dupuytren's  Contracture. 
It  occurs  in  the  palmar  fascia.  It  has  nothing  to  do  with  the 
tendons.  It  is  a  superficial  lesion.  It  is  infinitely  more  com- 
mon in  men.  It  is  characterized  by  a  gradual  closing  of  the 
fingers,  which  are  held  in  a  pathognomonic  position  as  though 
by  bands  of  steel.  As  it  is  often  bi-lateral,  a  central  cause  has 
been  suggested  for  it.  Probably  chronic  irritation  favors  this 
sclerosis,  although  it  is  by  no  means  uncommon  among  men 
who  have  done  but  little  manual  labor. 

The  figure  shows  that  the  hand  assumes,  (no  doubt  for  the 
convenience  of  ones  memory),  the  well  known  position  of 
Papal  Blessing  or  Apostolic  Benediction.  Were  it  not  for  this 
obliging  resemblance,  it  would  be  very  difficult  to  remember 
the  fact  that  the  lesion  occurs  almost  entirely  in  the  fascia  lead- 
ing to  the  ring  and  little  finger. 

Treatment.  The  open  and  the  closed  methods  are  advo- 
cated. By  the  open,  some  cocaine  is  introduced  and  a  longitu- 
dinal section  is  made  directly  over  the  steel  like  band  of  fascia. 
This  band  is  tensed  by  traction  on  the  closed  finger.  After  a 
little  dissection  it  easily  comes  into  view,  is  sectioned  proxim- 
ally  and  distally,  and  as  much  as  possible  of  it  is  removed.  The 
subcutaneous  method  consists  in  making  a  series  of  sections 


50 


SENSORY  NERVES,  UPPER  EXTREMITY. 


of  the  tense  band  with  a  fine  tenotome.  It  occasionally  gives 
good  results,  but  as  a  rule  is  to  be  utterly  condemned  because, 
as  time  goes  on,  more  sclerosed  tissue  grows  as  a  result  of  the 
traumatism  and  irritation  of  the  operation.  Tenotomy  is,  to- 
day, practically  the  only  closed  operation  that  has  survived. 


Fig.  9 


z-^ 


TT~^CT  of  0)770.7^ 

c)j[cy/o/Y^Dtyc6e.7)7)A^ 


t  ;    ,-j 


;  'n  V 


C.KS 


Fig.   10 


51 


DIFFERENTIAL. 


Dupuytren's  Con- 
tracture. 


Ulnar  Section. 


Median  Section. 


Burn 


Contract- 
ure. 


History  of  Injury. 


Absent. 


Onset  extremely 
slow;  begins  lit- 
tle finger. 


Male. 


Unable  to  let  go 
after  takinghold 
Sensation  nor- 
mal. No  wast- 
ing. Posture : 
typical ;  aposto- 
lic blessing. 


Cut  near  wrist  us- 
ually. 


Cut  near  wrist  us- 
ually. 


Disease. 
Onset  immediate.   Immediate. 
Sex. 


Male. 


Male. 


Disability. 


Unable  ^  grasp 
objects  normal- 
ly. Loss  of  sen- 
sation as  in  Fig. 
10.  Atrophy  of 
hypothenar, 
eminence  mark- 
ed. Posture: 
typical;  claw- 
hand. 


Small  objects  can 
not  be  picked 
up  by  thumb 
and  fingers. 
Loss  of  sensa- 
tion as  in  Fig.  10 
Atrophy  of  the- 
nar eminence 
marked.  Post- 
ure: typical. 
Ulnar  flexion  with 
extension  of 
wrist  and  fin- 
gers. 


Burn  of  severe  de- 
gree. 


Moderately    slow. 


Negative. 


Depends  on  extent 
and  position  of 
the  burn.  If 
nerves  were  de- 
s  t  r  o  y  e  d ,  the 
parts  supplied 
by  them  will  un- 
dergo  the    four 

characteristic 
changes  cited 
below.  Posture: 
atypical. 


Note  four  important  points  in  diagnosis  of  nerve  section : 
Atrophy,  Paralysis,  Anasthesia,  Posture. 

Note  also  that  every  nerve  which  crosses  a  joint  supplies 
filaments  to  all  the  soft  parts  as  well  as  to  the  hard. 


TENDONS  AND  TENDON  SHEATHS. 

Tendons  are  more  freqtiently  the  scene  of  operative  inter- 
vention than  muscles.  This  word  is  used  advisedly  instead  of 
interference,  because  the  surgeon  does  not  "interfere."     The 


•53  TENO-SYNOVITIS. 

Tendon  Sheaths  are  exquisitely  delicate  sacs  much  like  dimin- 
utive pleurae.  They  are  subject  to  inflammatory  changes,  not 
dissimilar  to  those  which  occur  in  the  great  sac.  One  charac- 
teristic sign  of  pleurisy  is  the  see-saw  friction  rub  heard  as  the 
patient  breathes.  It  can  sometimes  be  felt.  Similarly,  in  the 
small  sac,  dry  inflammatory  processes  go  on.  The  smooth 
bearing  surfaces  usually  so  well  oiled  and  presenting  infin- 
itesimal obstruction  to  motion,  become  dry  and  corroded. 
On  pulling  the  tendon  back  and  forth  after  this  change  has 
taken  place,  they  emit  a  grating  sound  and  transfer  what  is 
called  a  fremitus  to  the  hand.  This  is  known  as  tenosynovitis. 
It  is  usually  an  acute  or  sub-acute  lesion,  and  it  occurs  fre- 
quently in  the  tendo- Achilles.  "Tender  feet"  who  have  over 
indulged  in  walking  often  fall  a  prey  to  it. 

Chronic  teno-synovitis  is  present  in  most  cases  of  tuber- 
culous joints.  It  is  characterized  by  an  increase  in  the  size 
and  number  of  the  inflammatory  particles  characteristic  of  the 
acute  form.  These  may  gradually  grow  until  they  finally  be- 
come detached.  They  are  soft  at  firsfr  but  ultimately  undergo 
calcareous  degeneration.  After  this  they  are  known  as  rice- 
bodies.  Most  of  these  formations  contain  in  their  center 
tubercle  bacilli.  It  frequently  happens  that  the  chronic  form 
of  teno-synovitis  as  in  the  case  of  many  other  lesions,  usually 
originates  in  the  acute.  Obviolisly  the  chronic  form  is  amen- 
able only  to  operative  treatment. 

Tendons  often  have  to  be  cut  to  correct  muscle  contrac- 
tures. This  is  done  subcutaneously.  Repair  of  the  part  takes 
place  under  Schede's  moist  blood  clot  referred  to  on  page  25 
Consequently  great  care  should  be  exercised  not  to  allow  the 
dressings  to  press  out  the  blood  clot,  failure  of  which  to  organ- 
ize means  loss  of  function  in  the  part. 

A  felon  is  an  acute  inflammatory  process  in  the  distal 
phalanx  of  a  thumb  or  finger.  It  begins  on  the  palmar  surface. 
It  is  typically  a  periostitis,  although  the  other  soft  parts,  par- 
ticularly the  tendon  sheath,  may  be  primarily  involved.  Treat- 
ment consists  in  section  over  the  point  of  the  greatest  pain 
through  the  periosteum.  The  indication  for  this  section  is 
not  the  presence  of  pus  but  the  symptom  of  pain. 

Ganglion.  .    The    lay    name    for    this    is    weeping    sinew. 


BURSAE.  58 

Ganglia  are  now  thought  to  have  no  connection  at  all  with  the 
tendon  sheaths,  but  to  take  their  origin  from  the  synovial 
fringe  of  the  neighboring  joint.  They  are  therefore  a  form  of 
distention  cyst.  They  may  be  treated  by  rupture  subcutan- 
eously  or  by  aspiration  or  excision. 

Tendon  Transplantation,  This  is  often  useful  in  cases  of 
acquired  paralysis  of  the  extremities.  It  has  been  employed 
more  particularly  upon  the  foot.  It  consists,  for  example,  of 
inserting  a  slip  of  the  tendon  of  the  peroneus  longus  into  that 
of  the  tibialis  anticus.  It  is  of  value  only  in  rare  cases  where 
there  is  a  healthy  muscle  near  a  paralyzed  one. 

BURSAE. 

The  lesions  of  the  bursae  are  classed  as  occupation 
diseases.  They  are  the  result  of  exudative  and  productive  in- 
flammation. Morphologically  they  are  distention  cysts  caused 
by  long  continued  pressure.  Child  believes  them  to  be  essen- 
tially protective  rather  than  pathologic  in  nature.  From  hoary 
antiquity  we  have  inherited  the  following  old  classics : 

House  Maid's  Knee  or  pre-patella  bursitis  ;  Miner's  Elbow; 
rarely  seen  in  this  country,  but  frequently  in  England  and 
Wales,  where  the  coal  seams  are  so  narrow  that  the  men  are 
obliged  to  lie  on  their  sides  to  use  their  picks.  As  they  pick, 
the  elbow  rotates  back  and  forth  on  the  Olecranon  process 
and  the  bursa  enlarges.  Coachman's  Bottom.  This,  on  ac- 
count of  the  hard  seats  which  the  liveried  flunkies  of  the  British 
nobility  are  obliged  to  sit  upon,  combined  with  their  tight 
pants,  arises  on  the  tuber  ischii.  It  is  rarely  seen  in  this  coun- 
try because  of  adequate  upholstering. 


CHAPTER  V. 
LYMPHATIC  VESSELS  AND  THEIR  NODES. 


Fig.   11 

Shows  the  group  of  cervical  glands  typically  involved  in  syphilis. 
This  figure  is  designed  also  to  show  the  cervical  triangles  as 
simply  as  possible. 


ACTION  OF  THE  NODES.  55 

The  relation  of  the  lymphatic  vessels  to  diseases  in  general 
and  particularly  their  influence  upon  the  metastatic  distribution 
of  carcinomata  make  them  of  very  great  importance  surgically. 
A  thorough  knowledge  of  the  distribution  of  the  lymphatic  ves- 
sels which  drain  the  tongue,  the  breast  and  the  uterus  is  a 
sine  que  non  for  all,  but  most  particularly  for  those  wishing 
to  rank  in  a  hospital  examination.  The  character  of  the  opera- 
tions on  these  important  parts  is  governed  entirely  by  the  dis- 
tribution of  the  lymphatics. 

The  glands  may  well,  for  purposes  of  convenience,  be 
looked  upon  as  nature's  sieves.  They  protect  the  body  from 
germ  infection  and  other  dangers,  and  are  therefore  of  great 
surgical  importance.  They  do  not,  however,  bear  as  intricate 
a  relation  to  surgical  pathology  and  treatment  as  the  vessels. 

The  lymphatic  vessels  play  a  very  important  part  in  the 
distribution  of  germ  toxins  as  Avell  as  of  the  germs  themselves. 
The  glands  or  nodes  are  thought  to  filter  out  the  germs  them- 
selves much  more  efficaciously  than  their  chemical  products, 
although  it  is  well  known  that  in  passing  through  these  bar- 
riers of  infection,  the  toxins  are  greatly  moderated  in  their 
virulence.  Reciprocally  the  glands  are  enlarged  and  often  per- 
manently damaged.  It  is,  however,  in  the  protection  of  the 
body  against  invasion  of  the  actual  germ  bodies  themselves 
that  the  glands  show  to  the  best  advantage.  Their  well  known 
splenic  reticular  structure  seems  to  have  been  specially  devised 
to  entrap  the  invading  vegetable  hordes.  When  a  germ  is 
lodged  in  the  gland,  there  is  plasma  enough  and  leucocytes 
enough  in  this  vascular  organ  to  inhibit  its  development  if  not 
actually  to  kill  it  very  shortly  after  its  lodgement.  If  the  dose 
of  infection  at  the  primary  wotuid,  supposing  it  to  be  on  an 
extremity,  is  not  sufficiently  great  to  entirely  overwhelm  the 
lymphatic  nodes,  they  will  sieve  out  the  intruder  to  the  entire 
protection  of  the  general  organism.  If,  however,  the  dose  is 
overwhelmingly  large,  there  is  naturally  a  limit  to  the  number 
of  germs  they  can  accommodate,  and  the  result  is  that,  like 
sponges  filled  with  water,  they  can  take  no  more.  The  germs 
then  pass  on  and  are  swept  either  into  the  general  vascular 
stream  where  the  great  lymphatics  join  the  veins,  or  into  the 


56  TERMINATIONS. 

inner  breast  works  as  they  might  be  called,  of  lymphatic  nodes, 
unless  this  last  line  of  defense  has  already  been  passed. 

This  introduces  the  very  important  subject  of  lymphangitis 
and  lymphadenitis. 

This  is  not  an  inopportune  time  to  grind  out  these  various 
endings.  Very  few  students  know  them,  but  it  is  a  blessing 
to  realize  that  if  the  half  dozen  odd  terminations  are  once 
memorized  and  thoroughly  understood,  they  can  be  applied 
throughout  surgical  pathology. 

For  nerves,  for  the  stomach,  for  tendons  and  so  on  down 
the  line,  these  terminations  will  be  used. 

Lymphangitis.  "Itis"  means  inflammation  of.  Seen 
also  in  appendicitis,  gastritis,  otitis,  etc. 

Lymphadenoma.  "Adene"  in  Greek  means  a  gland,  so 
that  this  termination  means  a  lymphatic  grandular  swelling 
devoid  of  inflammatory  reaction. 

L5anphadenitis.  Here  the  two  terms  are  combined.  The 
"itis"  showing  that  the  enlarged  gland  has  undergone  inflam- 
matory change. 

Lymphangitis.  "Angi"  in  Greek  means  a  vessel.  This, 
therefore  signifies  an  inflammatory  condition  of  the  lymph  ves- 
sels. 

Lymphangiectasia.  "Ectasia"  in  Greek  means  dilatation. 
Therefore  this  term  as  applied  to  the  lymphatics  means  that 
the  lymphatic  vessels  are  dilated. 

Lymphangfiorrhaphy.  "Rhaphy"  in  Greek  means  a  line  of 
union.  It  is  seen  in  the  "median  raphe,"  a  term  familiar  to  all. 
Now  raphe  means  also  to  sew.  Whenever  it  is  suffixed  to  a 
word,  therefore  it  means  that  the  parts  have  been  sewn  to- 
gether. For  example,  enterorraphy  means  a  sewing  of  the  gut. 
This  naturally  is  rarely  practiced  in  the  case  of  lymphatic  ves- 
sels, because  they  are  too  delicate  to  sew  together,  but  at- 
tempts have  been  made  to  suture  the  thoracic  duct. 

Lymphangiostomy.  "Stoma"  means  mouth.  (Kindly  re- 
member that  this  has  nothing  to  do  with  stomach).  Stomatitis 
is  an  inflammation  of  the  mouth.  If  you  make  a  mouth  on  a 
thing,  it  implies  that  you  have  made  a  hole  in  it  for  good.  This 
differs  from  a  temporary  opening,  which  will  be  considered  in  a 
moment.     If  it  were  desired  to  make  a  fistula  to  drain  the 


DUCT  LESIONS.  57 

lymphatic  duct,  experimentally,  for  example,  this  would  be  a 
lymphangiostomy.  It  will  readily  be  noted  that  this  operation 
is  not  practically  used  on  the  lymphatic  vessels,  but  it  is  intro- 
duced here  to  show  that  theorectically  all  these  terminations 
can  be  applied  at  will  to  almost  any  organ.  The  familiar  opera- 
tion in  which  this  termination  is  used,  is  one  done  on  the  stom- 
ach and  it  is  therefore  called  gastrostomy. 

Lymphangiotomy.  "Temno"  in  Greek  means  to  cut.  If 
you  cut  into  a  vessel,  you  make  an  opening  into  the  lumen. 
Usage  has  determined  that  this  term  shall  apply  to  a  temporary 
opening  in  contra- distinction  to  the  one  just  considered  in 
which  "stoma"  is  used,  which  implies  the  making  of  a  perma- 
nent opening.  This  is  illustrated  particularly  well  on  the 
stomach.  A  gastrotomy  is  done  on  a  man  who  has  swallowed 
his  false  teeth.  It  is  immediately  closed  by  gastrorrhaphy.  If 
his  esophagus  is  destroyed,  however,  he  requires  a  gastrostomy. 

Lymphangiectomy.  "Ectomy"  is  derived  from  two  Greek 
expressions  "ec"  and  "temno"  "ec,"  meaning  out,  and  *'temno," 
to  cut.  "Angi,"  here,  as  elsewhere,  means  vessel.  Therefore 
this  long  word  means  simply  a  cutting  out  of  a  lymphatic  ves- 
sel. In  practice  this  is  rarely  deliberately  done,  the  fine  lyfn- 
phatic  vessels  being  removed  with  masses  of  other  tissue. 
The  terminations  are  used  very  frequently  to  denote  operations, 
on  other  viscera.  For  example,  neurectomy,  is  practised  for 
the  relief  of  sciatica ;  enterectomy,  a  removal  of  a  section  of 
the  enteron  or  gut  is  frequently  done  for  strangulated  hernia. 

Lymphedema.  From  the  Greek  "Oidos,"  a  swelling. 
This  means  a  transudation  into  the  areolar  tissue  of  lymph. 
It  is  generally  due  to  a  blocking  of  the  vessels.  It  is  distinct 
from  venous  edema  in  that  it  is  solid. 

Returning  from  this  excursion  into  etymological  fields,  it 
is  interesting  to  note  what  definite  relations  lymphatic  vessels, 
bear  to  disease  in  general. 

Filariasis.  This  is  the  general  term  for  a  series  of  symp- 
toms which  until  quite  recently  were  regarded  as  having  separ- 
ate entities.  They  are  called  into  being  by  the  presence  of  an 
animal  parasite  called  filaria  sanguinis  hominis,  yvhich  means 
the  thread  worm  of  man's  blood.  It  is  1-80  of  an  inch  long. 
The  embryos    are  harmless,  but  the  adults  produce  a  train  of 


•58  LYMPHADENITIS. 

symptoms,  the  like  and  diversity  of  which  is  not  paralleled  by 
any  other  known  organism.  One  of  the  most  important  of 
this  series  is 

Elephantiasis.  This  disease  is  rarely  seen  outside  the 
tropics.  It  is  a  productive  inflammation,  due  to  the  presence 
of  the  filaria  in  the  lymphatic  vessels.  This  occludes  the  vessels, 
and  ultimately  they  either  burst  or  degenerate  into  solid  strings. 
So  terrible  is  this  disease  in  its  ability  to  cripple  and  render 
useless  great  numbers  of  men  and  women  that  immense  prizes 
of  money  await  him  who  is  fortunate  enough  to  discover  its 
remedy. 

Chyluria.  This  symptom  is  also  produced  by  the  filaria. 
The  urine  looks  like  milk.  The  pathology  is  not  yet  under- 
stood. 

L5niiphadenitis  is  a  commonly  seen  swelling  of  the  nodes. 
It  is  due,  as  already  stated,  to  the  snaring  of  pyogenic  germs 
in  the  meshes  of  the  node  and  to  the  irritation  of  its  paren- 
chyma by  their  toxic  products.  The  parenchymatous  cells  are 
the  cells  which  do  the  specialized  work  of  an  organ.  They  are 
supported  by  the  interstitial  or  frame  creating  cells  which  unite 
to  hold  them  in  place.  Six  years  ago,  the  pus  producing  organ- 
isms were  supposed  by  many  to  be  confined  to  the  three  varie- 
ties of  the  streptococcus  and  the  staphylococcus,  viz. — the 
albus,  the  aureus  and  the  citreous.  This  list  has  now  been 
lengthened  to  over  thirty.  The  best  way  to  remember  it,  is 
to  learn  the  germs  that  do  not  produce  pus.  Prominent  among 
these  are  the  parasites  of  tetanus  and  diphtheria. 

Lymphadenitis  may  be  acute  or  chronic.  It  is  not  uncom- 
mon in  the  groin.  If  a  patient  is  found  to  have  a  swelling  of 
"the  glands  below  Poupart's  ligament,  look  for  a  sore  on  the 
foot.  If  the  cross  bar  of  the  lymphatic  T  is  involved,  look  for 
venereal  infection.  Acute  lymphadenitis,  particularly  when  the 
inflammation  is  localized  either  in  one  gland  or  in  glands  which 
are  close  together,  is  sometimes  called  bubo.  Bubo  is  from  the 
Greek  "Bonbon,"  meaning  groin,  but  the  term  is  also  occasion- 
ally used  to  denote  an  inflammatory  condition  in  glands  situ- 
ated elsewhere. 

The  treatment  is  palliative  or  radical.  If  the  infection  has 
T^een  of  such  a  degree  and  nature  as  to  kill  the  gland,  ice  bags 


LYMPHATICS  OF  FEMALE   GENITALS. 


59 


and  rest  will  do  no  good.  These  agents,  however,  should  al- 
ways be  employed,  and  it  is  well  to  remember  that  in  practically 
all  cases  of  acute  inflammation,  cold  is  indicated  during  the 
first  36  hours  and  moist  heat  after  that  time.  Moist  is  much 
more  efficacious  than  dry  heat. 

The  radical  method  of  treatment  consists  in  free  incision 
and  drainage.  The  after-treatment  is  very  tedious.  Attempts 
to  heal  these  lesions  rapidly  by  the  application  of  the  principle 
of  Schede's  moist  blood  clot  have  been  successful.  The  technic 
after  opening  and  curetting  is  simply  to  swab  the  cavity  out 
with  pure  carbolic  acid,  douching  it  immediately  with  alcohol. 
This  stops  further  action  of  the  acid.  This  method  of  treating 
abscess  cavities  has  recently  been  widely  adopted  by  many  New 
York  surgeons.  It  has  been  used  with  favorable  results  in 
thousands  of  cases  at  the  Hudson  Street  Hospital.  After  irri- 
gating with   the   alcohol,   the   incision    is   tightly   closed   with 


ZSody 


G 


CrviK 


*/ 


iJukC 


Uo^^ 


h»^ 


nJi 


XrcL</f 


Ce.ton'. 


«'  ^t'^V.;-^  ^ 


(^dt. 


To 


n 


VuLva 

Fig.  12 

Lymphatic  drainage  of  Female  Genitals.     (Frequently  asked) 


60  IMPORTANCE  OF  LYMPHATICS. 

sutures.  Chronic  inflammatory  conditions  have  been  fovmcl  to 
do  well  'under  this  form  of  treatment,  it  having  been  used  many 
times  for  tuberculous  bone  disease. 

Chronic  Lymphadenitis  occurs  typically  in  the  course  of 
three  general  diseases, — tuberculosis,  syphilis  and  pseudoleuke- 
mia. In  the  first  the  glands  are  often  removed ;  although  this 
may  be  followed  by  general  infection.  In  the  second,  they 
are  treated  constitutionally  and  sometimes  locally  by  mer- 
curials. In  the  third,  they  are,  unless  seriously  threatening  to 
life  or  function,  left  alone. 

A  most  admirable  series  of  diagrams  showing  the  relation 
of  the  lymphatics  and  their  nodes  to  surgical  procedures  are 
given  on  page  428  et.  seq.  of  "Park's  Surgery."  Eisendrath 
also  devotes  much  attention  to  the  subject. 

These  studies  of  lymphatic  drainage  have  been  the  deter- 
mining factors  in  establishing  the  present  technic  of  all  im- 
portant operations  for  the  removal  of  carcinomata.  This  form 
of  malignant  growth  is  believed  to  spread  entirely  along  the 
lymphatic  channels,  the  characteristic  enlargement  of  the  lym- 
phatic nodes  draining  the  involved  tissues,  affording  perinent 
evidence  of  in  support  of  this  belief. 


CHAPTER  VI. 

SHOCK. 

Crile  has  shown  that  the  complicated  condition  known  as 
surgical  shock  consists,  when  synthecized,  of  three  secondary 
symptoms.  These  are  loss  of  vasomotor  control,  disturbance 
of  respiration,  and  interference  with  cardiac  action.     For  the 

best  and  most  recent  presentation  of  the  subject,  reference  is 
made  to  Brewer's  text  book,  page  87,  where  the  academic  and 
clinical  questions  associated  with  it  are  fully  discussed. 

It  has  been  demonstrated  that  the  great  abdominal  veins 
can  hold  all  the  blood  there  is  in  the  body.  A  man,  therefore, 
under  certain  conditions  may  bleed  to  death  into  his  own  ab- 
dominal veins.  One  of  the  most  frequently  discussed  subjects 
in  connection  with  shock  is  the  question  of  establishing  a  differ- 
ential diagnosis  between  it  and  abdominal  hemorrhage.  Now 
truly  he  who  thinks  to  accurately  establish  such  a  diagnosis  is 
wise  beyond  his  years,  no  matter  what  his  age.  Why?  If  a 
patient  suffering  from  shock  has  bled  into  his  abdominal  veins, 
and  another  one  along  side  of  him  has  slipped  a  ligature  off, 
say  the  deep  epigastric  artery,  and  has  bled  into  the  cavity 
surrounding  the  veins,  what  important  difference  could  one 
expect  to  find  between  the  two?  That  the  differential  diagno- 
sis is  so  difficult  as  in  many  cases  to  be  impossible,  is  attested 
to  by  the  fact  that  the  most  expert  diagnosticians  may  be  ex- 
pected to  fail. 

Obviously,  the  need  of  making  this  differential  diagnosis 
is  found  chiefly  among  those  cases  in  which  the  traumata  have 
been  limited  entirely  to  the  abdomen,  signs  of  hemorrhage 
elsewhere  being  easily  recognized. 

Another  factor  which  obviously  increases  the  difficulty  of 
establishing  a  differential,  is  that  every  case  of  hemorrhage 
has  associated  with  it  a  certain  amount  of  shock.  In  other 
words,    every   case   which   bleeds   into    its   abdominal    cavity, 


62         .  SHOCK  DIFFERENTIALS. 

bleeds  also  into  its  partially  paralyzed  abdominal  veins.  It 
therefore  becomes  practically  a  question  of  degree. 

Perhaps  the  one  distinguishing  feature  between  hemorr- 
hage and  shock,  outside  of  the  history,  is  the  attitude  of  the 
patient.  In  shock,  he  is  said,  as  a  rule,  to  be  apathetic,  whereas 
in  hemorrhage,  there  is  often  a  tendency  to  excitement.  The 
excited  form  of  shock  is  not,  however,  uncommon. 

Efforts  have  been  made  to  differentiate  the  two  by  a  blood 
examination,  but  the  results  have  not  yet  been  positive. 

Because  of  the  failure  to  differentiate  shock  from  internal 
hemorrhage,  many  persons  have  been  killed.  Nature's  method 
of  controlling  hemorrhage  is  to  slow  the  heart  until  coagulation 
in  the  wound  takes  place.  This  is  why  strong  men  faint  at 
the  sight  of  blood.  Nature  means  to  slow  that  man's  heart 
the  moment  he  is  cut.  Evidently  the  thing  to  do  is  to  leave 
cases  of  internal  hemorrhage  alone,  unless  abdominal  or  vaginal 
section  can  be  done.  The  treatment  of  shock  is,  on  the  other 
hand,  to  stimulate  the  heart.  If  therefore,  shock  be  mistaken 
for  hemorrhage,  the  patient  is  promptly  killed  by  having  the 
heart  stimulated  so  that  it  pumps  what  little  blood  he  has  left 
out  through  the  torn  artery. 

A  differential  which  is  not  rare  is  between  fat  embolism 
and  shock.  This  dreaded  sequel  of  injury  to  the  long  bones 
is  much  more  frequent  than  is  usually  supposed,  a  great  many 
cases  of  shock  being  mistaken  for  it.  Acvite  suppression  of 
urine  and  pulmonary  oedema  have  also  to  be  differentiated 
from  shock. 

Treatment.  Surgical  shock  as  before  noted  is  almost  al- 
ways associated  with  more  or  less  hemorrhage.  The  patient 
is  cold,  pale  and  apathetic.  The  abdomen  is  not  the  only  site 
where  the  body  fluids  have  collected.  They  are  also  stagnating 
in  the  extremities.  The  brain  is  relatively  dry.  The  indica- 
tions for  treatment  are  cardiac  stimulation, — external  heat — 
this  should  be  applied  as  vigorously  as  possible.  Posture, — 
pour  blood  into  the  head  by  elevating  the  patient's  feet.  En- 
teroclysis, — this  consists  in  turning  the  patient  as  nearly  upside 
down  as  possible,  and,  in  the  absence  of  the  customary  layout, 
of  inserting  a  large  funnel  as  far  into  the  rectum  as  possible. 
Through  this  funnel  is  poured  a  couple  of  litres  of  water  at 


TREATxMENT  OF  SHOCK.  63i 

a  temperature  of  49C  (120  F.)  Add  two  heaping  teaspoonfuls. 
of  NaCl.  In  osmosis,  when  the  fluid  is  absorbed,  the  lighter 
fluid  passes  much  more  rapidly  through  the  membrane  than: 
the  denser.  Fresh  water  should  therefore  be  absorbed  from 
the  rectum  more  rapidly  than  salt  solution.  It  is,  however,, 
more  irritating  to  the  mucous  membrane  and  is  therefore  rarely 
used.  The  position  in  which  the  patient  is  held  enables  the 
filuid  to  run  down  as  far  as  and  across  the  transverse  colon. 
It  is  worth  remembering  that  in  the  treatment  of  shock,  as  in 
that  of  threatened  death  from  anesthesia,  one  of  the  first  things 
to  be  done  is  to  turn  the  patient  upside  down.  Gravity  will  do- 
a  great  deal  to  overcome  cerebral  anemia,  as  is  well  shown  by 
the  recovery  of  an  over-chloroformed  mouse  when  hung  up  by 
the  tail. 

Infusion  is  another  means  of  introducing  fluid  into  the- 
system.  The  execution  of  this  technic  requires  a  suitable 
canula  connected  with  a  cistern,  and  a  certain  amount  of  exper- 
ience is  necessary  to  carry  it  out  effectively  and  speedily.  In 
this  case,  unlike  that  of  the  rectum,  it  is  absolutely  necessary 
that  the  salt  solution  should  be  prepared  so  as  to  be  of  practi- 
cally the  same  specific  gravity  as  the  blood.  Otherwise,  many- 
corpuscles  will  be  crenated  and  much  damage  will  be  done  tO' 
the  oxygen  carrying  power  of  the  blood.  Air  must  not  be  ad- 
mitted for  air  bubbles  are  as  dangerous  as  fat  globules. 

Hypodermoclysis  is  another  method  of  introducing  water 
into  the  body.  It  consists  simply  in  connecting  a  large  hol- 
low needle  with  a  douche  bag,  the  bag  is  filled  with  salt  so- 
lution at  120°  and  the  needle  is  plunged  into  a  region  of  soft 
cellular  tissue,  either  beneath  the  breast  or  in  the  yielding- 
regions  of  the  back.  Kemp  has  obtained  important  results  in 
applying  this  method  to  conditions  of  diminished  or  suppressed 
urine.  Either  of  the  preceding  methods  will  introduce  fluid 
more  rapidly  than  this  one.  Fifty  or  more  cubic  centimeters- 
of  salt  solution,  however,  injected  by  hypodermoclysis  over  the- 
region  of  the  kidney  will,  in  chosen  cases,  produce  four  or  five 
times  the  amount  of  urine  in  an  astonishingly  short  time. 

Elastic  compression  of  extremities  is  an  expedient  which 
has  been  used  for  shock,  notable  by  Dawbarn.  A  strong  elas- 
tic band  is  placed  about   the   extremity  near  the  body,  after- 


^d  TREATMENT  OF  SHOCK. 

most  of  the  blood  has  been  forced  out  of  it  either  by  compres- 
sion or  by  posture.  After  say  ten  minutes,  during  which  time 
the  extremity  has  been  deprived  of  its  normal  circulation,  the 
blood  is  allowed  to  flow  into  it  and  another  extremity  is  treated 
in  the  same  way. 

What  might  be  called  the  inverse  of  this  plan  has  been 
used  for  the  treatment  of  coal  gas  poisoning.  By  tightening 
the  elastic  enough  to  stop  the  return  circulation,  the  extremity 
is  allowed  to  fill  as  full  as  the  heart  will  pump  it.  By  this 
means  a  considerable  percentage  of  the  poisoned  body  fluids 
are  shut  up  in  the  extremity  for  a  short  time,  during  which 
the  lungs  and  other  purifying  agents  of  the  system  have  a 
better  chance  to  get  rid  of  the  poisonous  products  than  if  they 
were  dealing  with  the  entire  mass.  So  the  extremities  may 
be  used  as  reservoirs  of  the  body  fluids,  to  be  emptied  and  filled 
at  will. 

Immediate  Operation.  Relief  from  shock  can  generally 
be  obtained  by  following  the  palliative  treatment  outlined.  In 
cases  of  very  severe  injury,  however,  radical  treatment  may 
become  necessary.  As  in  the  case  of  tetanus,  it  is  imperative 
to  thoroughly  remove  the  focus  of  infection  as  well  as  to  treat 
the  symptoms.  So  in  shock,  it  is  important  under  certain  con- 
ditions to  remove  the  cause.  There  are  two  ways  of  doing 
this.  First,  the  mutilated  tissues  may  be  amputated.  This 
exchanges  for  a  multiple  set  of  nerve  wounds,  single  wounds 
which  naturally  do  not  send  as  many  complaints  to  headquar- 
ters as  in  the  case  of  the  primary  multiple  injury.  Second,  the 
mutilated  nerves  may  be  cocainized.  This  is  best  done  by  in- 
jecting 3  or  4  per  cent,  solution  at  the  site  of  the  injury,  or  a 
much  weaker  solution  into  the  torn  nerves,  proximal  to  the 
wound. 

An  application  of  the  principle  of  the  elastic  bandage  as 
used  on  the  extremities,  is  well  seen  in  the  use  of  Crile's  pneu- 
matic rubber  suit.  It  resembles  a  diver's  costume,  being  so 
arranged  that  by  inflating  it,  increased  atmospheric  pressure 
can  be  brought  to  bear  upon  the  entire  surface  of  the  body  ex- 
cept the  head,  and  the  field  of  operation.  It  is  designed  to  force 
the  blood  from  the  surface  and  from  the  extremities  into  the 
starved  cerebral  circulation,  and  because  more  extensive  should 
be  more  efficacious  than  the  bandage. 

Of  all  drugs  indicated  in  the  treatment  of  shock  undoubted- 
ly the  most  valuable  is  the  remarkable  non-toxic  vaso-motor 
stimulant  adrenalin. 


CHAPTER  VII. 
SEPSIS;  ACUTE. 


Jit,.'  J  <)(•*""' 


F«.-'    "/"- 


Fig.  IB 

This  is  adapted  from  Eisendrath's  Clinical  Anatomy.  It  shows 
very  clearly  how  sepsis  may  travel  by  cotitinuity  from  the 
face  to  the  Internal  Jugular  and  by  contiguity  to  the  Brain 
and  its  Membranes. 

I  By  courtesy  of  Db.  Eisendrath) 

Brewer,  page  41  of  text  book,  presents  this  subject  more 
tersely  and  intelligibly  than  any  one  else.     He  says : 

"Septicemia,  Pyemia  and  Septic  Intoxication, — although 
formerly  considered  separate  diseases,  these  three  conditions 
are  best  regarded  simply  as  different  types  of  acute  general 
sepsis.  Whenever  pathogenic  bacteria  gain  access  to  and  grow 
in,  the  systemic  circulation  and  tissues,  the  condition  is  re- 
ferred to  as  septicemia.  If,  on  the  other  hand,  stich  general- 
ized infection  be  associated  with  the  development  of  foci  of 
suppuration,  it  is  designated  pyemia.  The  term  septic  intoxica- 
tion is  used  to  indicate  a  condition  due  to  the  absorption  of 


66  TEMPERATURE  TABLE. 

toxins  mainly  of  bacterial  origin.  Sapremia  is  a  term  some- 
times employed  to  signify  a  form  of  intoxication  due  to  absorp- 
tion of  the  poisons  of  putrefactive  micro-organisms.  It  is  not 
always  possible  to  distinguish  sharply  between  infections  and 
intoxications,  indeed,  the  manifestations  of  infectious  disease 
are  nearly  always  referable  to  bacterial  poisons." 

One  of  the  first  things  suggested  by  a  consideration  of 
sepsis  is  temperature. 

The  following  table  of  temperatures,  with  all  the  failings 
of  an  emperic  classification,  has  points  of  merit. 

Given  a  patient  convalescent  from  some  such  simple  opera- 
tion as  an  interval  appendectomy. 

(i)  One  to  twelve  hours  after  operation,  temperature  loi. 
This  is  post-operative  reaction,  and  has  been  ascribed  to  dis- 
turbance of  the  thermo-genetic  centers. 

(2)  Twelve  to  twenty-four  hours  after  operation,  tem- 
perature loi.     What  is  it? 

Probably  what  is  known  as  surgical  fever  or  aseptic  wound 
fever.  This  is  uncommon  if  there  has  been  heavy  hemorrhage. 
It  is  also  unlikely  to  occur  if  no  blood  has  accumulated  in  the 
wound  after  operation.  It  is  due  to  the  absorption  of  blood 
clot,  ligatures,  and  possibly  antiseptic  solutions. 

(3)  Twenty-four  to  thirty-six  hours  after  operation,  tem- 
perature 102.  This  is  auto-intoxication  from  the  bowels  and 
is  remedied  by  a  purge. 

(4)  Thirty-six  to  seventy-two  hours  after  operation,  tem- 
perature loi  and  rising.  This  is  the  real  thing,  for  this  inter- 
val represents  the  average  period  of  development  required  by 
the  pyogenic  germs. 

(5)  After  seventy-two  hours,  out  of  the  woods.    . 
Treatment  of  all  nurse,  feed  and  stimulate.     In  addition, 

for  (2),  dry  wounds;  for  {3),  catharsis.  Wash  rectum  and 
colon.  For  (4),  drainage,  antiseptics,  antitoxin-sera,  infu- 
sions, Crede's  ointment. 

Recovery  has  been  known  to  take  place  between  the  ex- 
treme temperatui-es  of  75.2°  and  1 14.8°  F.     (Br.  Med.  Jour.  Feb,. 

7-  "04)  • 


67 


diffp:rential  between 


Tetanus. 


Stkychnink. 


Hydrophoiua. 


Lyssophobia. 
(lyssa-rage) 


Punctured  wound. 


Incubation  8  to  1 
days. 


History  ok  Injury. 
Overdose.  Bite. 

Disease. 
Immediate.  Ten  weeks. 

Al^E. 


Babies  and  adults  Adults. 


Children    and 
adults. 


Negro. 


Increases  as  Equa- 
tor is  approach- 
ed. 


Sore  throat.  Later 
may  be  agoniz- 
ing. 


Stiffness  of  cervi- 
cal and  maxil- 
lary muscles. 
Inability  to 
open  mouth. 


Not  constant. 


Irregular. 


Race. 
Negative.  Negative. 

Climate. 
Negative.  Central  Europe. 

Pain. 

Often  in  back.         j  In  wound. 

! 

Disability. 


Jaws  not  rigid  at 
first. 


Defective    speech 
and  inspiration. 

Deglutition 
spasms. 


Vomiting. 
Frequent.  Absent. 

Bowels. 
May  be  diarrhea   |  ?\cgative. 


Bite. 


Irregular:  typical- 
ly within  a  week 


Adolesence. 


Latin  Races. 


Southern  Europe. 


Marked  mental. 


May  imitate  any 
or  all  symptoms 
of  others. 


Often  present. 


Constipated. 


68 


DIFFERENTIAL  BETWEEN.— Co.ntinukd. 


Tetanus. 


Strychnine. 


HyDROI'HODIA. 


Lyssophobia. 

(lyssa-rage) 


■99  to  100. 


98   to  100,   except 
after  a  spasm. 


Temperature. 

99.5  to  102.5 


98.6   or   sub  -  nor- 
mal. 


Respiration. 


Dyspnea      during 
paroxysme. 


Dyspnea,    not 
marked. 


Respiratory 

spasms. 


Irregularly  parox- 
ysmal. 


Mind  clear. 


Nervous  Symptoms.     (Central) 

p.  Melancholia.    De- 

®     ■  lirium  common. 


Hysterical    mani- 
festations. 


Paresthesiae. 


Peripheral. 


Green  vision  and 
retinal  hyperes- 
thesia. 


Nerve  irritation  or 
exhaustion. 


Parasthesiae. 


Sardonic  grin. 


Negative. 


GENERAL  PHYSICAL. 

Facies. 


Anxious. 


Negative. 


Anxious  and 
drawn. 


Nutrition. 


May  be  diminish- 
ed. 


Excited,    anxious. 


Typically  deprav- 
ed. 


REFLEXES. 


Clonic  exacerba- 
tions converting 
spastic  rigidity 
into  violent  and 
convulsive  mus- 
cular activity. 


Tonic  exacerbati's 
with  intervals  of 
rest. 


Increased. 


Diminished  or  in 
creased. 


LOCAL  PHYSICAL. 


In  nearly  one-half 
w  o  u  n  d  is  on 
foot  or  hand. 


No  wound. 


Bite   frequent    on  „•.  v,^^^ 

r  ^  Bite  anywhere. 


69 


DIFFERENTIAL  BETWEEN.— Continued. 


Tktanus. 


Strychnine. 


Hydrophobia. 


Lyssophobia. 
(lyssa-rage) 


LABORATORY  FINDINGS. 

Blood. 

Leucocyte  Count. 


11,000. 


Negative.  j  Negative. 

I 
Injection. 

I  I 

Probably  fatal.        Negative.  |  Probably  fatal. 


Tissue  Section. 


Neighborhood  of 
wound  filled 
with  bacilli. 


Negative. 


Acute    hyperemia 
of  wound  tissue 


Normal. 


Negative. 


Wound  tissue  nor- 
mal. 


There  are  other  diseases  or  groups  of  symptoms  which 
may  be  differentiated  from  these  four.  One  frequently  con- 
founded with  tetanus  is  Tetany.  It  resembles  tetanus  only  in 
name  and  in  the  fact  that  occasionally  the  same  muscle  groups 
are  attached  with  spasms.  It  may  have  a  nervous  or  an  auto- 
intoxicational  origin.  It  is  uncommon  in  this  country  and  has 
a  zero  mortality  rate. 

SEPSIS;   CHRONIC. 

As  already  stated,  Brewer's  classification  of  the  infectious 
surgical  diseases  presents  them  in  a  very  simple  and  easily 
understood  form.  The  chronic  infections  which  have  a  surgi- 
cal bearing,  are  tuberculosis,  syphilis,  and  actionomycosis. 

Tuberculosis,  otherwise  known  as  the  White  Man's 
Flague,  kills  one  out  of  seven.  By  far  the  greater  number  of 
these  deaths  are  caused  by  infection  of  the  lungs  or  brain. 
These  are  as  yet  practically  beyond  surgical  intervention. 
There  is,  however,  no  known  part  of  the  body  which  the  tuber- 
cle germ  has  not  invaded. 

In  the  chapter  on  inflammation,  the  onion  like  formation 
of  the  typical  tubercle  was  discussed,  it  being  noted  that  the 


70  SURGICAL  TREATMENT  OF  TUBERCULOSIS. 

irritation  produced  by  the  establishment  of  the  tubercle  germ 
in  the  tissues  resembled  in  miniature,  and  in  a  way  easily 
studied,  the  more  vigorous  and  destructive  action  of  other 
germs.  The  onion  like  series  of  hollow  spheres  enveloping  the 
part  were  particularly  noted.  It  was  not  stated,  however,  that 
the  work  of  the  fibroblasts  in  the  case  of  a  tubercle  does  not 
end  with  the  mere  formation  of  scar  tissue.  In  tuberculosis 
Nature  goes  a  step  further  in  the  protection  of  the  organism, 
by  causing  calcification  of  the  scar  tissue.  When  patients  are 
sent  to  the  mountains,  the  air  furthers  scar  formation  and 
calcification  more  rapidly  than  it  does  in  the  lowlands  and 
particularly  in  the  cities.  After  perhaps  a  year's  sojourn  in 
the  hills,  the  patient  is  allowed  to  return.  Often  within  a  few 
days,  supposing  the  infection  to  have  been  pulmonary,  he 
begins  to  cough  and  to  expectorate.  What  has  happened? 
Lowland  air  is  not  as  friendly  to  the  newly  developed  scar  tis- 
sue as  air  of  the  uplands.  Some  has  broken  down  and  has 
allowed  the  impounded  germs  to  escape.  In  other  words, 
calcification  of  these  little  areas  has  not  been  allowed  to  com- 
plete itself  and  the  patient's  life  has  been  placed  in  jeopardy 
by  bringing  him  home  too  soon. 

Tuberculosis  then  is  cured  by  Nature's  process  of  walling 
the  germ  ofif  within  a  limestone  shell.  These  little  shells  be- 
come incysted  in  the  tissues  and  remain  there  as  harmless 
foreign  bodies  throughout  life.  It  is  also  sometimes  cured  by 
spontaneous  extrusion  of  the  germs. 

What  is  man's  method  of  curing  tuberculosis?  Simply 
a  following  of  Nature.  We  may  help  her  to  incyst  or  to 
extrude.  The  Radical  method  or  treatment  by  open  incision 
has  very  distinct  limitations.  The  conservative  method,  or 
treatment  by  rest  and  extension  has  a  much  wider  field.  The 
first  is  practised  by  the  general  surgeon,  the  second  by  the 
orthopedic  surgeon. 

What  determines  the  falling  of  a  given  case  of  surgical 
tuberculosis  into  the  hands  of  one  class  or  the  other?  Just 
one  condition,  and  that  one  alone.  If  the  infection  be  a  pure 
one,  that  is  to  say  if  there  are  no  pyogenic  germs  in  conjunc- 
tion with  the  tubercular  germs  the  man  of  plaster,  pulleys  and 
weights  should  have  the  say.     If,  however,  pyogenic  germs  be 


HIP-JOINT  TUBERCULOSIS.  71 

present,  the  man  with  the  knife  cannot  too  quickly  aid  Nature 
in  her  effort  to  cast  them  out  of  the  body. 

For  it  is  to  be  noted  that  the  "walling  off"  method  is  not 
Nature's  only  means  of  curing  tuberculosis.  Under  certain 
conditions  she  agrees  to  let  them  stay  within  the  organism, 
making  them  harmless  by  putting  a  stone  wall  around  them, 
but  under  other  conditions,  she  breaks  open  the  skin  and 
crowds  the  offenders  out.  This  accounts  for  the  existence  of 
these  two  distinct  classes  of  surgeons.  They  each  do  their 
work  in  accordance  with  one  of  Nature's  methods,  simply 
giving  a  hand  to  help  her  out. 

What  is  the  etiology  of  the  average  case  of  surgical  tuber- 
culosis? It  may  be  said  in  general  that  tuberculous  lesions 
arise  from  moderate  acute  injuries,  once  inflicted,  whereas 
malignant  lesions  arise  from  infinitely  slight  injuries  many 
times  inflicted. 

A  little  child  falls  from  its  crib  to  the  floor,  cries  with  pain, 
puts  his  hand  on  his  hip,  and  in  six  weeks  has  the  early  char- 
acteristic symptoms  of  coxitis.  An  old  Irishman  with  broken 
tooth  or  rough  T.  D., — year  in  and  year  out  wounds  and  irri- 
tates his  lip  until  the  epithelioma  grows. 

PURE  CULTURE,  SURGICAL  TUBERCULOSIS. 

A  consideration  of  this  immense  field  is  outside  the  scope 
of  this  book.  Pure  culture  tuberculosis  gives  bread  and  butter 
ta  the  orthopedic  surgeon.  Some  of  the  most  interesting 
lesions  of  this  class  are : 

Coxitis.  This  is  also  known  as  hip  joint  disease.  Its  etiol- 
ogy has  been  given.  The  great  majority  of  the  cases  can  be 
traced  to  minor  injuries  which  were  neglected.  The  pathology 
is  that  of  wet  productive  inflammation  which  later  on  becomes 
practically  dry.  This  is  of  course  supposing  the  case  to  remain 
free  from  mixed  infection.  The  tubercle,  if  it  produces  pus  at 
all,  does  so  in  such  very  small  cjuantities  that  the  system  may 
be  said  to  be  always  able  to  carry  it  away  and  never  under  the 
necessity  of  extruding  it  through  the  skin.  This  happens 
typically  only  when  mixed  infection  occurs. 

The  symptoms  are  perhaps  more  important  than  those  of 


73  KNEE-JOINT  TUBERCULOSIS. 

any  other  chronic  disease,  for  the  utility  or  perhaps  the  life 
of  the  individual  depends  upon  their  early  recognition. 

If  a  recent  preparation  is  made  in  the  dissecting  room,  with 
ligaments  in  place  but  everything  else  removed,  the  pelvis  being 
savvied  in  two  through  the  median  line  antero  posteriorly  and 
the  femur  cut  at  about  its  middle,  a  demonstration  can  be  made 
which  probably  explains  the  position  assumed  in  the  first  stage 
of  hip  disease.  The  extremity  is  abducted  and  externally  ro- 
tated. Students  often  get  the  idea  that  the  first  stage  is  internal 
rotation  and  adduction.  It  is  not.  It  is,  however,  too  often  the 
first  stage  in  the  eyes  of  the  general  practitioner,  to  the  eternal 
misfortune  of  the  child. 

Take  the  preparation  above  alluded  to  and  bore  a  hole 
through  the  ilium  opposite  the  head  of  the  femur.  Screw  in 
a  hollow  tap  and  connect  it  with  a  water  pump.  Hold  the 
preparation  up  and  the  femur  assumes  a  position  governed  by 
gravity.  Force  in  water,  and  the  bone,  as  though  it  were 
alive,  will  slowly  but  surely  rotate  externally  and  abduct  itself 
from  the  mid-line.  So  closely  does  this  experiment  simulate 
the  process  which  must  take  place  in  nature,  that  it  affords 
incontrovertible  evidence  that  the  parts  assume  the  position 
of  external  rotation  and  abduction  in  the  first  stages  simply 
because  the  joint  is  full  of  water.  By  rotating  the  head  of  the 
femur  in  that  direction  the  joint  cavity  will  hold  more  water 
than  in  any  other  position  of  the  bone. 

The  second  position  of  the  extremity  is  characteristic.  It 
is  the  result ;  the  direct  result  as  was  the  first,  of  the  inflamma- 
tory process.  An  understanding  of  this  process  should  prevent 
any  one  from  making  any  mistake  about  it.  It  is  caused  by 
contractures  due  to  the  normal  and  usual  process  of  productive 
inflammation.  There  is  no  better  example  in  the  whole  of 
medicine  than  coxitis,  of  how  easy  it  is  to  predict  the  symptoms 
of  a  case  by  simply  working  them  out  on  the  basis  of  inflamma-  , 
tion.  It  is  footless  to  memorize  these  symptoms.  Know  what 
to  expect  from  a  thorough  acquaintance  with  the  inflammatory 
process  and  there  isn't  a  disease,  the  bulk  of  whose  symptoms 
you  cannot  accurately  predict  without  ever  having  seen  a  case 
or  read  a  word  on  the  subject. 

A    third    stage    is    sometimes    described.      Like    the    big 


EPIPHYSITIS. 


78 


fibroids  weighing  forty  pounds,  it  is  rarely  seen  in  these  days. 
You  are  in  luck  if  the  gynecologists  ever  let  you  see  a  fibroid 
weighing  ten  pounds,  let  alone  forty,  and  you  cannot,  except 
in  most  densely  ignorant  communities,  expect  to  see  a  child  in, 
the  pitiable  advanced  third  stage  of  coxitis. 


Fig.   14 

Acute  femoral  epiphysitis  in  child  eight  years  old.  Lesion  ap- 
pears as  white  oval  in  the  epiphysis.  Note  patella  and  fibula, 
also  the  wide  separation  of  epiphysis  from  diaphysis. 

The  adduction  and  internal  rotation  has  gone  on  and  com- 
bined with  such  a  degree  of  flexion  that  deep  sores  may  be 
made  on  the  well  leg  by  pressure  of  the  contractured  sick  side. 
The  patient  has  been  unable  to  walk  for  months  and  perhaps, 
for  years. 

The  differential  diagnosis  of  the  many  forms  of  hip  disease 
is  of  the  gravest  importance. 


74 


DIFFERENTIAL  IN  CHILD  BETWEEN 


Tuberculous 
Coxitis. 


Syphilitic 
Coxitis. 


Coxa- Vara. 


Rheumatism. 


Slight,     single, 
acute. 


Onset  insidious. 


Occasionally  in 
lungs  or  else- 
where. 


Marked. 


Marked. 


100  to  102. 


110. 


32  to  26. 


Negative,  unless 
meningitis  com- 
plicating. 


History  of  Injury. 
Absent.  I  May  be  present. 

History  ok  Disease. 


Usually  in  parent. 
May  rarely  be 
acquired.  Onset 

slow. 


Nutritional  d  i  s  - 
turbances.  On- 
set very  slow. 


Previous  Disease. 


Negative. 


Evidences   of    ra- 
chitis. 


Pain. 

Marked,  worse  a'l  t.,.   ,  ,  , 

.   ,  ,  Slight  or  absent, 

night.  ^^ 

I 

DlSAlJILITY. 

Variable. 


Marked. 


99  to  101. 


110. 


■i2  to  26. 


TeMI'ERATUKE. 

Normal. 

Pulse. 

!:30  to  90, 
Resi'iration. 
23. 


Absent. 


In     other     joints. 
Onset  acute. 


Tonsilitis,  con- 
j  unctivitis, 
rheumatic  dia- 
thesis. 


Marked. 


Very  marked. 


102  to  104. 


120. 


26  to  30. 


NERVOUS  SYMPTOMS. 
Central. 


Neofative. 


Negative. 


Mav  b3  delirium. 


75 


DIFFERENTIAL  IN  CHILD  BETWEEN.— Continukd. 


Tuberculous 
Coxitis. 


Syphilitic 
Coxitis. 


Coxa-Vaka. 


Rhkumatism. 


GENERAL  PHYSICAL. 

Facies. 


Drawn. 


Normal  or  slightly 
below. 


Square  face  of  ra- 
chitis. 


..        ,  .^      .  General,    discreet 

Absent,  If  primary      i^^.^lvement. 


Old  man. 

Nutrition. 
Always  bad.  May  be  fat. 

Glands. 

Absent. 


Evidence  of  pain. 


Negative. 


Absent. 


LOCAL  PHYSICAL. 

Inspection. 


First  stage,  ab- 
duction, exter- 
nal rotation. 
Apparent  leng- 
thening. 


Same  as  T.  B.  in 
early  stage. 


Eversion,     appar- 
ent shortening. 


Palpation. 


Adduction  and  in-| 

ternal     rotation 'Same  as  T.  B. 
painful. 


Extreme  abduc- 
tion impossible, 
but  not  painful. 


Trochanter  in  nor- 
mal position. 


Tuberculin. 


Mensuration. 
Same  as  T.  B. 

Effect  ok  Drugs. 
Mixed   treatment.   Negative 


Trochanter  often 
above  Neleton's 
line. 


Variable,  but  of- 
ten abducted 
and  externally 
rotated. 


A 1 1  movements 
painful,  but  par- 
ticularly adduc- 
tion and  inter- 
nal rotation. 


Normal. 


Salicylates. 


The  knee  is  a  favorite  site  for  pure  culture  tuberculous  in- 
fection. The  T.  B.  germ  has  a  predilection  for  new  rapidly 
growing    parts,    presumably    because    they    are    tender.      The 


76 


PURE  CULTURE  TUBERCULOSIS. 


epiphysis  is  consequently  a  favorite  site.  The  "accompanying- 
figure  of  a  radiogram  of  epiphysitis  of  the  knee  of  a  child  not 
alone  shows  the  lesion  of  epiphysitis  very  beautifully,  but  also 
demonstrates  what  a  large  and  tangible  structure  the  epiphysis 
is.  It  is  often  erroneously  thought  of  as  a  line,  but  it  is  in  fact 
a  good  sized  solid  body  throughout  childhood.  Reference  is 
suggested  to  Brewer's  text  book,  page  520,  where  a  diagram  is 
shown  giving  the  time  of  bony  union  of  the  epiphyseal  junc- 
tions. On  the  good  old  principle  that  the  "Last  shall  be  first 
and  the  first  shall  be  last,"  the  bones  last  formed  are  first  to 
unite,  the  first  formed  the  last  to  unite. 

Pure  culture  infection  of  the  ankle  is  not  infrequent.  It 
has  frequently  to  be  differentiated  from  syphilis,  rheumatism 
and  flat  foot. 

DIFFERENTIAL  IN  YOUNG  ADULT  BETWEEN 


Tuberculosis  of 

TlBIO-FIBULO- 
TARSAL     OR    InTER- 

Tarsal  Joints. 


Syphilis  of 
Same. 


Rheumatism   of 
Same. 


Flat  Foot. 


Moderate  acute 
and  neglected. 


May  be  secondary 
Onset  slow. 


May   or   may   not 
be  absent. 


History  of  Injury. 
Absent. 


History  of  Disease. 


Chancre.       Onset 
slow. 


Diathetic   signs. 
Onset  rapid. 


Negative. 


None. 


Severe,  constant. 


Malformation. 
Negative.  Negative. 

Previous  Injury. 
None.  None. 


Pain. 


Severe,    worse    at 
night. 


Very  acute. 


Often  present,  ei" 
ther  acute  or 
chronic. 


Often  during  con" 
valesence  from 
wasting  disease 


Often  short  tendov 
Achilles. 


Often  follows  bad- 
ly set  Pott's 
Fracture. 


Only  on    bearing 
weight  of  body. 


77 


DIFFERENTIAL  IN  YOUNG  ADULT  BETWEEN.— Continued. 


Tuberculosis  of 

TlBIO-FIBULO- 
TARSAL     OR    InTER- 

Tarsal  Joints. 


Syphilis  of 
Same. 


Rheumatism  of 
Same. 


Flat  Foot. 


Marked. 


Disability. 


Marked. 


Complete. 


Variable,  but  al- 
ways present  to 
some  degree. 


LOCAL  PHYSICAL. 

Inspection. 


Drop  foot.  Swell- 
ing not  red,  ta- 
pering,  (if  old). 


Drop  foot,  dark 
red,  localized 
swelling. 


Drop  foot,  scarlet, 
localized  swell- 
ing. 


Palpation. 


Negative,  save  for 
diffuse  tender- 
ness and  pain 
over  most  mark- 
ed area  of  infec- 
tion. 


Same. 


Diffuse  tender 
negs.  Pain  over 
joint  line. 


Tuberculin 
tion. 


Improvement. 


Drug  Administration. 


Mixed  treatment.     Salicylate. 


Mechanical  Treatment. 


Improvement. 


No  improvement. 


Loss  of  arch,  pro- 
minence of  peri- 
neal tendons 
and  scaphoid. 


Absolutely  char- 
acteristic points 
of  tenderness: 
(1)  Internal  mal- 
leolus; (2) Inter- 
nal calcaneo- 
navicular  liga- 
ment; (8)  Over 
center  of  sole 
due  to  stretch- 
ing of  plantar 
ligament;  (4) 
Dorsal  junction 
of  a  astragalus 
and  navicular ; 
(5)  External 
malleolus. 


Negative. 


Stretch   tendon  if 

necessary. 
Arch  curative. 


The  treatment  of  all  these  pure  culture  forms  of  infection 
if  they  attack  the  joints  as  they  usually  do,  is  summed  up  in 
few  words, — Essence  of  time  and  tincture  of  patience. 


78 


PURE  CULTURE  TUBERCULOSIS. 


Immobolize;  extend,  and  unless  the  infection  becomes 
mixed,  you  should  have  a  cure  in  a  large  per  cent  of  cases,  in 
about  the  same  time  as  it  took  the  patient  to  get  sick. 

Pure  culture  surgical  tuberculosis  is  also  seen  very  fre- 
quently in  the  bodies  of  the  vertebrae.  The  inflammatory  re- 
actions produced  in  this  case  are  grouped  together  under  a  set 
of  symptoms  generally  known  as  Pott's  Disease.  Like  all 
other  pure  T.  B.  infections  it  is  absolutely  essential  that  it  be 
recognized  early  to  insure  protection  of  the  parts  from  injury. 
Neglect  is  the  most  potent  cause  of  mixed  infection.  Its  early 
differential   diagnosis   is   therefore   paramount. 

DIFFERENTIAL  BETWEEN 


Spondylitis. 
(Pott's  Disease) 


Scoliosis. 
(Curvature) 


Hysterical 

Spine. 


Spinal  Sprain. 


May    be    slight 
knuckle. 


Frequent,  but  not 
invariable. 


Evidence  of  germ 
infection.  Onset 
slow. 


Possible. 


History  of  Tumoe. 

May  be   tumefac-l 
tion,    but    more  Absent, 
diffuse. 


Injury. 
Possible,  but  rare 


Present  or  absent, 
according  to 
whim  of  patient 


Negative.      Onset 
very  slow. 


Disease. 

Onset  often  acute 


Absent. 


Severe,  always 
present. 


Onset  always  im-- 
mediate. 


Previous  Injury. 


Carrying  loads  on 
one  side  or  sit- 
ting in  badly 
built  school 
chair. 


Frequently  the 
suggesting 
agent. 


Negative. 


Previous  Disease. 


Frequently    his- 

„       .,,  J        tor  v    of    ante- 

Possiblv     second-       •      ^     , 

..,.  V  R  .1«..,  ""I  polyo-mye- 
litis  but  rarely 
recognized  as 
such. 


ary.    T.  B.  else- 
where. 


Frequently     chlo-j 

rosis  and  uterine  Negative, 
disorder. 


79. 


DIFFERENTIAL  BETWEEN.— Continukd, 


Spondylitis. 
(Pott's  Disease) 


Scoliosis. 
(Curvature) 


Hystkrical 

Sl'INE. 


Spinal  Sprain. 


Children. 


Negative. 


Marked  on  mov- 
ing. Belly-ache 
wakes  from 
sleep. 


To  jump,  abso- 
lute ;  to  walk  in 
upright  posi- 
tion, increasing. 
Grunting  respi- 
ration. 


Evening  rise,  99  to 
101. 


Pain  referred  to 
parts  enervated 
by  nerve  escap- 
ing near  lesion. 
Bi-lateral.  Cen- 
tral origin. 


Adolesence. 


Female. 


Age. 

Young  adult. 

Sex. 

Female. 

Pain. 


Very  slight  if  any. 


Constant,  but  does 
not  waken 
from  sleep. 


Disability. 


Weakness,  no  pos- 
itive disability. 


Depends  on  abili- 
ty of  patient  to 
simulate  Pott's. 


Temperature. 


Normal. 


Often  96  to  98. 


Paresthesiak. 


If  present,  often 
due  to  pressure 
of  rib  on  inter- 
costal nerve. 
Frequently  uni- 
lateral. Peri- 
pheral. 


Not  referred.  Lo- 
cated just  one 
side  or  the  other 
of  the  spines, 
usually  at  one  or 
other  of  the  typ- 
ical hysterical 
points. 


Adult. 


Male. 


Severe,  e.specially 
during  certain 
movements. 


Often  limited  to, 
doing  the  exer- 
cise which  caus- 
ed it,  for  exam- 
ple, lifting. 


Normal. 


Localized  over- 
site  of  ligamen- 
tous rupture. 


Knee-jerk  may  be 
exaggerated. 


GENERAL  PHYSICAL. 
Reflexes. 


Negative. 


Absent,  normal  or 
exaggerated. 


Negative. 


■80 


DIFFERENTIAL  BETWEEN.— Continued. 


Spondylitis. 
(Pott's  Disease) 


Scoliosis. 
(Curvature) 


Hysterical 
Spine. 


Spinal  Sprain. 


LOCAL  PHYSICAL. 


Inspection. 


Sin  gl  e,  sha  rp 
knuckle  may  be 
present. 


If  kyphotic  in 
type  (rare),  it 
may  closely  sim- 
ulate-Pott's. 


May  seem  to  be  a 
prominence  of 
several  spines 
(owing  to  usual 
extreme  t  h  i  n  - 
n  e  s-s  of  patient 
and  to  the 
tact  that  they 
droop  the  shoul- 
ders, which 
partly  obliter- 
ates the  normal 
lumbar  lordosis) 


Palpation. 


No  tenderness  on 
pressure. 


Same. 


Marked  tender- 
ness. 


Negative. 


Tenderness     over 
traumatism. 


Effect  of  Extension  and  Immobilization. 


Marked  improve- 
ment within  a 
week. 


Continued  and 
progressive  dis- 
ability. 


No  improvement. 


Immediate  relief. 


It  can  readily  be  seen  that  a  differential  between  Pott's 
and  scoliosis  of  the  kyphotic  type  is  by  no  means  easy.  It  is 
nevertheless  of  very  great  importance,  for  in  order  to  obtain 
the  best  results  the  one  should  be  put  at  absolute  rest  in  exten- 
sion, while  the  other  should  be  pulled  and  hauled  and  mauled 
and  exercised  up  to  the  very  last  limit  of  the  patient's  en- 
durance. 


81 


MIXED  CULTURE  TUBERCULOUS  INFECTIONS. 


These  should  rightly  fall  under  the  care  of  the  general 
surgeon  as  they  usually  call  for  iminediate  radical  treatment. 
Some  of  the  more  frequent  differentials  of  this  group  in  the 
knee  region  are  as  follows : 


Acute 
Osteomyelitis. 


Acute 
Epiphysitis. 


Rheumatism. 


Septic 
Arthritis. 


If  present,  not 
marked.  Often 
absent. 


Within    33  to  72 
hours. 


May    be    pyemia. 
Typhoid,  etc. 


Child. 


Very  severe.  Bet- 
ter if  tumor  ap- 
pears. 


Not  present   in 
joint. 


Usual. 


History  ok  Tumor. 
Present. 


Frequently     pres- 
ent. 


In'jury. 
Same.  Absent. 

Previous  Disease. 
Same  Diathesis. 

Age. 
Child.  Child  or  youth. 

Pain. 

Same. 
Disability. 


Slight  in  joint 


Same. 


Marked  in  joint. 
Vomiting. 

Occasional. 


Present,    may    be 
marked. 


33  to  73  hours. 


Pneumonia  or  the 

like. 


Any  age. 


Same. 


Same. 


Very  frequent. 


Early. 


NERVOUS  SYMPTOMS. 
Delirium. 

Same.  Present  if  severe. 


Early. 


83 


DIFFERENTIAL  BETWEEN.-^Continued. 


Acute 
Osteomyelitis. 


Acute 
Epiphysitis. 


Rheumatism. 


Septic 
Arthritis. 


White  or  light  red. 
Slight  swelling 
usual.  Absent 
if  periostium  not 
involved.  On 
diaphysis. 


Pus  often  not 
reached  except 
by  bone  section. 
May  be  only  a 
drop. 


LOCAL  PHYSICAL. 

Inspection. 


Red.  Swelling 
constant  and 
early;  in  neigh- 
borhood of  joint 
Localized  either 
above  or  below 
it,  unless  sec- 
ondary joint  ef- 
fusion present. 


Crimson.  General 
swelling  of  joint 
very  marked. 
Joint  outline 
gone. 


Exploratory  Incision. 


Pus   apt  to   be 
nearer  surface. 


No  pus.  Often 
much  fluid.  May 
show  charac- 
teristic germ 


Dusky  red.  Swell- 
ing marked. 
Outline  of  joint 
obliterated. 


Quantities  of  pua 
free  in  joint. 


CHAPTER  VIII. 
SYPHILIS  AND  GONORRHEA. 

Syphilis  is  one  of  the  most  interesting  of  all  diseases.  We 
are  all  more  or  less  profoundly  infected  with  it.  If  we  were 
not,  primary  syphilis  would  kill  thousands  upon  thousands  of 
people,  whereas  it  is  known  to  have  practically  a  zero  mortality. 
There  is  a  large  stock  of  good  lively  racial  antitoxin  on  hand 
which  is  the  product  of  our  ancestors"  struggles  for  life  against 
this  invasion.  This  antitoxin,  like  other  individual  characteris- 
tics, is  handed  on  to  the  child  through  the  agency  of  the  ovum 
and  the  spermatozoon.  As  in  the- case  of  other  characteristics 
transmitted  through  these  agents,  the  inherent  resistance  of 
individuals  to  syphilitic  infection  varies  profoundly.  Some  ap- 
pear to  be  as  immune  as  goats,  whereas  others  have  been 
granted  but  little  immunity. 

It  is  only  300  years  ago  since  primar}^  syphilis  killed  count- 
less thousands  of  Europeans.  Historically  the  course  of  this  dis- 
ease is  marvellously  interesting ;  suffice  it,  however,  to  say  that 
during  the  restless  period  of  European  development,  wh-en  Na- 
ples was  infested  by  the  armies  of  France  and  of  Spain,  the  dis- 
ease was  so  rife  among  the  soldiers  and  killed  such  numbers  of 
them  that  the  French  called  it  the  Italian  disease,  the  Italians 
called  it  the  French  disease,  and  the  Spaniards  were  at  liberty 
to  choose  between  the  two.  Any  one  who  is  further  interest- 
ed in  this  remarkable  scourge  will  find  a  fascinating  account 
of  it  and  its  ravages,  as  well  as  the  attempts  which  been 
made  to  control  it,  in  that  masterpiece,  Sanger's  "History  of 
Prostitution." 

Due  to  some  infectious  agent,  the  character  of  which  is  un- 
known, this  disease,  in  an  individual  to  whom  has  been  granted 
the  usual  amount  of  racial  resistance,  pursues  a  course  which, 
for  constancy  of  symptoms  on  the  one  hand,  and  for  mimicry 
on  the  other,  far  excels  and  surpasses  any  known  disorder. 
What  the  actual  cause  may  be  for  the  fact  that  certain  indi- 


•84 


INFLAMMATORY  MANIFESTATIONS  OF  SYPHILIS. 


viduals  are  endowed  with  a  greater  resisting  power  than  others,' 
is,  of  course,  conjectural,  but  if  protection  in  syphilis  arises,  as 
history  seems  to  show  it  to  do,  by  ancestor  infection,  it  is  prob- 
able that  these  fortunate  individuals  had  incestors  of  question- 
able morals.  Thus  arises  the  possible  ethical  question  as  to 
what  our  attitude  should  be  toward  establishing  protection  for 
posterity. 


^mT^' 


o^ 


^-^ 


Fig.  15 

Scheme  for  drawing  the  articulations  of  the  wrist.     This  composit 
joint  is  occasionally  invaded  by  syphilis. 

The  syphilitic  inflammatory  process,  whatever  its  activity, 
or  whatever  its  virulence,  has  one  constant  factor.  It  begins  on 
the  surface  of  the  body  and  marches  relentlessly,  slowly,  but  as 
surely  to  the  center.  It  may  take  twenty  years  to  make  this 
short  journey,  but  unless  retarded  by  incessant  treatment,  make 
it,  it  will.  This  conception  of  the  disease  is  a  convenient  way 
of  interpreting  or  of  predicting  the  symptoms  of  the  three 
classical  stages  which  are  familiar  to  all.  Like  every  other 
lesion,  its  course  must  be  studied  from  the  standpoint  of  in- 
flammatory reaction.  In  its  long  career  it  gives  manifestation 
of  every  possible  phase  of  inflammation.  More  properly  speak- 
ing, it  affords  excellent  proof  that  the  classification  of  inflam- 
matory reactions  which  has  been  developed  to  facilitate  its 
study,  is  simply  an  arbitrary  division  into  several  classes  all 


LAWS  GOVERNING  SYPHILITIC  INFECTION.  85 

part  and  parcel  of  one  process.  They  are  too  apt  to  be  looked 
upon  as  having  separate  entities  with  distinct  modes  of  devel- 
opment. 

Syphilis  is  the  most  perfect  mimic  of  all  diseases.  It  might 
aptly  be  called  the  Pathological  Clown.  So  many  times  has  it 
deceived  the  most  astute  diagnosticians  that  one  of  them  pro- 
pounded the  well  known  wary  phrase :  "When  in  Doubt 
Give  K.  I."  From  headache  on  the  one  hand  to  toe  ulcer  on 
the  other,  there  is  not  a  condition  for  which  this  remarkably 
versatile  disorder  may  not  be  mistaken.  For  this  reason  the 
number  of  differentials  between  syphilis  and  its  likenesses  is 
simply  innumerable.  A  number  have  already  been  touched 
upon.  Conclusion  is  often  impossible  except  by  aid  of  treat- 
ment, which  in  time  reveals  the  true  nature  of  the  case. 

No  less  certain  than  the  classic  course  of  symptoms  in  this 
disease  is  the  degree  of  probability  of  its  occurrence  in  certain 
definite  cases.  These  have  been  carefully  studied  and  have 
been  grouped  according  to  certain  laws. 

Colle's  Immunity. — This  law  refers  to  the  mother. 
It  signifies  that  immunity  which  exists  in  healthy  mothers 
who,  owing  to  the  presence  of  syphilis  in  the  father,  have  had 
syphilitic  offspring.  The  mothers  escape  all  clinical  evidence 
of  syphilis. 

Prof  eta's  Immunity. — This  refers  to  the  child.  It 
is  the  immunity  which  exists  in  the  children  of  syphilitic 
parents.  In  many  such  cases,  the  father  or  mother,  one  or 
both,  being  syphilitic,  the  children  nevertheless  remain  healthy. 
Any  explanation  of  these  extraordinary  facts  must,  in  the 
light  of  our  present  ignorance  of  the  nature  of  the  syphilitic 
infection,  be  purely  hypothetical.  The  most  probable  belief  is 
that  the  child  of  syphilitic  parents  is  infected  with  the  anti- 
bodies (racial)  in  excess  of  the  pro-bodies  (parental).  In  addi- 
tion to  the  racial  anti-bodies,  the  child  creates  individual  anti- 
bodies by  the  usual  method  of  reciprocal  production.  By  this 
overdose  he  is  spared  the  clinical  manifestations  of  syphilis  and 
grows  to  healthy  adult  life. 


DIFFERENTIAL  BETWEEN 


Labial  Chancre 


Epithelioma. 


Chancroid. 


Herpes. 


Slight  elevation. 


Absent. 


Signs  of  systemic 
infection.  Incu- 
bation 10  days 
to  3  weeks. 


Negative. 


Not  possible. 


Young  adult. 


Female. 


Always  absent. 


Marked. 


to  101 


History  ok  Tumor. 
Absent. 

Injury. 

Moderate    chronicl  ^^^^^^ 
and  multiple. 

History  ok  Disease. 


No    incubation. 
Onset  very  slow. 


No  incubation. 


Absent 


Acute  irritation. 


May  complicate  a 
neurosis,  cold  or 
fever.  No  incu- 
bation. 


Almost  invariably 
present. 


Previous  Injury. 
Negative. 


Previous    Disease. 


Often  elsewhere. 


More  common  af 
ter  40. 


Male,  2000%  more 
frequent  than 
female. 


Often  severe. 
(May  be  referr- 
ed) 


Not  marked. 


May  be  elsewhere 
Age. 

Young  adult. 
Sex. 

Negative. 
Pain. 

Typically  present. 
Disability. 

Marked. 


Negative. 


Same. 


Any  age. 


Negative. 


Present- 


Normal. 


Temperature. 

103  to  103. 


Very  marked. 


Normal. 


87 


DIFFERENTIAL  BETWEEN.— Continukd. 


Labial  Chancre. 


EpITHKHOMA.  CHANCIiOIl). 


Herpks. 


GENERAL  PHYSICAL. 
Gkands. 


Early;  discreet, 
epitrochlear  first 
involved. 


Oriiy  glands  of  lo- 
cal drainage. 
Late  infection. 


Same,    but    early 
infection. 


No  enlargement. 


LOCAL  PHYSICAL. 

Inspection. 


Single  or  simulta- 
neously multiple 
Round  or  sym- 
metrically ir- 
regular. Super- 
ficial. Either  lip. 
Red  glazed  scab. 
Secretion  scanty 
serous. 


Typically  hard. 
Ends  abruptly 
in  normal  skin. 


Single. 

Un  symmetrically 
irregular. 

Superficial. 

Lower  lip. 

Fungous  granula- 
tions. 

Hemorrhagic. 


Often  multiple. 

Unsymmetrically 
irregular. 

Punched  out. 

Either  lip. 

Worm  eaten  bot- 
tom. 

Purulent,  abun- 
dant. 


Palpation. 


Solid,  but  not  hard 
unless  thickly 
crusted. 


Typically  soft. 


Multiple  and  con- 
fluent. 
Irregular. 
Superficial. 
Either  lip. 
Pultaceons. 
Moderate. 


Same  as  chancroid 


BLOOD. 

Differential  Leucocyte. 


Lymphocytes,  40- 
50^.  Polymor- 
phonuclear 45- 
60%.  Hemoglo- 
bin 50-60%. 


Negative. 


May  fall  as  low  asLy 

II    ^^,flbot^         Negative. 


.b7    (Cabot) 


Inflammatory  evi- 
dence. 


Not  indicated  but 
Hg.  will  modify 


Typical  pearl  nest 
formation. 


Negative. 


Color  Index. 

Negative. 
Tissue  Section. 
Atypical. 


Drug  Administration. 


No  effect.    X-Ray 
heals. 


Antiseptics  heal. 


Negative. 


Negative. 


Atypical. 


Antiseptics  heal. 


88  GONORRHEAL  PYEMIA. 

Syphilitic  infections  of  the  hard  or  soft  parts,  particularly 
in  the  late  secondary  and  tertiary  stages,  ofifer  pleasing  ground 
for  mixed  infection.  Hence  it  often  becomes  necessary  to  sub- 
ject them  to  radical  surgical  treatment.  In  this  event  one  of 
the  most  useful  diiiferentials  is  between  Gumma  and  Sar- 
coma. The  chancre,  which  is  the  characteristic  lesion  of  the 
primary  stage,  has  often  to  be  differentiated  from  epithelio- 
mata.  This  is  a  bit  of  side  light  which  shows  the  relation  of 
these  four  lesions  to  the  surface  and  to  the  deeper  structures 
of  the  body. 

Syphilis  is  the  most  frequent  cause  of  Dry  Productive  In- 
flammation, The  sclerosis  of  the  kidneys  and  liver  kill  thou- 
sands of  men  and  women.  The  same  lesion  invades  the  cord, 
causing  90  per  cent,  of  cord  diseases,  while  our  asylums  are 
overburdened  with  the  victims  of  syphilitic  brain  sclerosis. 

Remotely,  then,  syphilis  has  a  tremendous  mortality  rate. 

GONORRHEA. 

This  second  rate  acute  infectious  disease  has  no  right  to 
be  associated  with  a  lesion  so  abstruse,  so  separate,  and  so  dis- 
tinct from  it  as  syphilis.  It  is  one  of  the  most  typical  acute 
septic  infections.  Probably  the  explanation  for  their  having 
been  placed  cheek  by  jowl  in  most  text  books  is  to  be  found  in 
the  importance  of  the  one  point  which  they  have  in  common, 
viz.,  the  frequency  of  their  venereal  origin.  The  chief  interest 
to  be  found  in  a  study  of  gonorrhea  lies  in  the  occasional  mani- 
festation of  the  pyemic  capability  of    the  germ. 

Especially  under  such  favorable  conditions  as  epididimo- 
orchitis,  acute  gonorrheal  prostatitis,  or  cystitis,  the  germ  occa- 
sionally wanders  out  in  considerable  numbers  into  the  general 
circulation  and  becomes  localized  at  some  point  of  minimum 
resistance.  Such  a  point  is  often  a  joint,  and  the  knee  joint  is 
particularly  prone  to  fall  prey  to  it.  This  condition  of  localiza- 
tion of  the  cocus  in  or  about  the  joints  has  been  erroneously 
called  Gonorrheal  Rheumatism.  There  might  be  some  excuse 
for  it  if  it  resembled  in  any  way  acute  mono-articular  rheuma- 
tism, which  is  undoubtedly  of  germ  origin,  but  unhappily,  it  is 
anything  but  acute  in  its  course.     The  moment,  furthermore, 


GONORRHEAL  ARTHRITIS. 


8J^ 


that  mono-articular  rheumatism  so  called  is  proved  to  have 
a  septic  nature  it  ceases  to  have  claim  to  the  word  "rheuma- 
tism." 

Gonorrheal  Arthritis,  then,  is  the  name  of  the  day.  The 
treatment  of  this  condition  has  in  the  past  been  most  unsatis- 
factory. It  is  safe  to  say  that  no  treatment  whatsoever,  save 
one,  either  local  or  constitutional,  has  any  influence  upon  the 
course  of  the  disease.  Its  tendency  is  toward  recovery,  but  the 
processes  of  productive  inflammation  have  so  long  been  active 
that  the  joint  is  always  more  or  less  impaired  because  it  is 
filled  with  scar  tissue. 

The  Modern  Method  of  Treatment. — Rather  than  let  a 
man  walk  around  on  crutches  for  two  years  during  the  most 
active  part  of  his  life,  rather  than  subject  him  to  the  pain  of  all 
forms  of  counter-irritant  local  treatment,  it  is  now  deemed  ad- 
visable to  cut  boldly  across  the  joint  as  Mayo  has  recommended 
should  be  done  in  case  of  acute  septic  arthritis  and  prevent 
the  productive  inflammatory  changes  by  washing  away  their 
creators.  Copious  irrigation  and  prolonged  soaking  in  mildly 
antiseptic  solutions  are  said  on  very  good  authority  to  be  dis- 
tinctly curative  of  this  condition.  One  of  the  possible  lesions, 
with  which  gonorrheal  arthritis  may  be  confounded  is  pure 
culture  tubercvdous  arthritis  and  another  is  chronic  articular 
rheumatism. 


DIFFERENTIAL  BETWEEN 


Gonorrheal 
Arthritis. 


Rheumatic 
Arthritis. 


Pure  Tubercu- 
lous Arthritis. 


Loose  Body  in 
Joint. 


History  of  Tumor. 


Moderate,    diffuse 
swelling. 


May  be  absent. 
Occasionally  lo- 
calized. 


Apparent  tumor 
due  largely  to 
wasting  above 
and  below. 


Comes    and    goes, 
suddenly. 


History  ok  Injury. 


Absent. 


Absent. 


Frequently     pres- 
ent.   Slight. 


Almost    certainly 
present.  Severe. 


90 


DIFFERENTIAL  BETWEEN— Continued. 


Gonorrheal 
Arthritis. 


Rheumatic 
Arthritis. 


Pure  Tubercu- 
lous Arthritis. 


Loose  Body  in 
Joint. 


Specific  complicat- 
ed urethritis. 


Negative. 


Young  adult. 


Very  infrequent 
in  female. 


Not  referred.  Con- 
stant, grinding 


History  of  Disease. 


Negative.  Negative. 


Previous  Disease. 


Involvement  else- 
where. 


Often     secondary 
to  lungs. 


Age. 


Over  40 


Adolescence. 


Sex. 


Pain. 


Varies  with  baro- 
metric pressure. 


Constant  but 
worse  at  night 
if  bone  involved 


Disability. 


Often  complete 
for  long  periods 
if  over-exercised 
Remissions. 


100  to  102    during 
exaserbation. 


Depends  almost 
entirely  on  cli- 
matic conditions 
of  temperature, 
pressure,  mois- 
ture, electrical 
state. 


Progressi  ve  ly 
complete.  No 
periods  of  inter- 
mission. 


Temperature, 


Rarely  elevated. 


Evening  rise  99  to 
101. 


Onset  sudden. 


Not  infrequently 
a  sequel  of  trau- 
matic arthritis. 


Young  adult. 


Male. 


Irregular  exacer- 
bations at  inter- 
vals when  body 
i  s  caught  in 
joint. 


Complete  with 
marked  periods 
of  intermission. 


Normal. 


GENERAL  PHYSICAL. 

Inspection. 


Gleet. 


Swollen  joints 
elsewhere. 


Pulmonary     cavi-  ^         .^ 


ties 


91 


DIFFERENTIAL  BET  WEEN.— Continued. 


Gonorrheal 
Arthritis. 


Rheumatic 
Arthritis. 


Pure  Tubercu- 
lous Arthritis. 


Loose  Body  in 
Joint. 


LOCAL  PHYSICAL. 

Inspection. 


Dark  red,  swollen 
joint. 


Warm.  (For  local 
temperature, 
palpate  with 
back  of  hand 
which  is  more 
sensitive  than 
palm.) 


Often  1  to  2  inches 
enlargement. 


Often  very  little 
redness  and  mo- 
derate swelling 


Characteristically 
white,  very  mo- 
derate swelling. 
May  be  only  ap- 
parent. 


Palpation. 


Cold. 


Colder    than 
well  knee. 


the 


Mensuration. 


Yz  in.  to  1  in. 


Little   or    no    en- 
largement. 


May  be  small  lo- 
cal tumor  show- 
ing position  of 
foreign  body. 


Hot,  if  recovering 
from  exacerba- 
tion. 


Same  as  well  side. 


Exudate.  Sp.  Gr- 
over  1010  and 
containing  go- 
nococci.  Much 
albumin. 


Negative. 


Negative  .save  for 
partial  relief  of 
pain. 


LABORATORY  FINDINGS. 

Puncture. 

If  present,  transu-'  ^         "  ■,   , 
date.       Sp.    Gr.|Tf'^^"^^^«     ^o"' 
1001-1005      Lit-:      ^^^°^°S      occas- 
tle  albumin.   No^      ^^"^^       ^-  ^- 
germs. 


germs. 


Effec'i  of  Drugs. 


Often   very    help- 
ful. 


Reaction  from  tu- 
berculin. 


Mechanical  Treatment. 


Hydrotherapy  and 
dry  heat,  may 
improve. 


Marked  improve- 
ment under  ex- 
tension and  im- 
mobilization. 


Exudate.      No 
germs. 


Negative 


Freedom  from  at- 
tacks by  immo- 
bilization. Oc- 
casionally cura- 
tive. 


92 


ISCHIO  RECTAL  FOSSA. 


•  datteti   iine     shows    its   juncn.n 

1  '""^    Sufer-ff^a.?  ■fxsc'ia. 


7  ^cfiio  •  Ca  i^er-noSu  s 


Tufc/a. 


(frca.t'     OcUff-  Sc.ra,'^ 


yirsssfs  a  ltd 


^f  ?tenr£. 


Toirtt    7* 


YK.     /s   SCm. 


ISCHIO-RECTAL  FOSSA. 

Two  inches  deep,  one  inch  wide. 
Base  formed  by  integument  of  ischio-rectal  region. 
Apex  at  angle  of  division  between  obturator  and  recto-vesical  fascia. 

Boundary. 

Base  of  triangular  ligament. 

Its  junction  with  the  superficial  fascia.    (Dotted  line) 
Obturator  fascia. 
Tuber  ischii. 

Great  sacro  sciatic  ligament.    (Note  that  it  extends  as 
far  as  coccyx). 
2.     Gluteus  maximus. 

1.  Sphincter  Ani. 

2.  Levator  Ani.     (Owing  to  the  fact  that  its  insertion  is 
on  a  lower  plane  than  its  origin). 

3.  Coccygeus.     (As  it  lies  in  same  plane  as  the  above). 

Internal  Pudic  Vessels  and  Nerve. 
Inferior  Hemorrhoidal  Vessels  and  Nerve. 
Superficial  Perineal  Vessels  and  Nerves. 
A  Branch  of  4th  Sacral  Nerve. 
Adipose  Tissue. 


Anteriorly. — 1 . 
2. 

Externally. — 1 . 
2. 

Posteriorly.  — 1 . 


htternally. 


Contains. — 1. 
2. 
3. 
4. 
5. 


GONORRHEAL  INVASIONS. 


953 


/Sc/7t 


Ohi-ut-afor     /yrf- 


77  •/cr  ncif 


Sfoh, 


n^c/^ 


^0°     ^/eya^^'on      of      The      J='^c c  e ^ , -ncf 
Fig.  17 

One  of  the  worst  possible  sequels  of  gonorrheal  urethritis 
is  gonorrheal  prostatitis.  Not  infrequently  it  goes  on  to  ab- 
scess, and  although  it  now  seems  probable  that  the  enlarge- 
ment of  the  prostate  is  due  to  gravitational  rather  than  to  infec- 
tious causes,  it  is  at  least  not  a  good  thing  to  have  had  a 
gonorrheal  infection  of  the  prostate.  In  a  number  of  symptoms 
this  condition  simulates  cystitis. 

There  is  a  latent  area  immediately  posterior  to  the  pubic 
symphysis,  the  function  of  which  is  not  understood,  and  which 
is  therefore  commonly  looked  upon  as  fortuitous  in  occurrence. 
This  is  probably  erroneous,  because  it  undoubtedly  has  some 
function.  It  is  called  the  space  of  Retzius.  In  practice,  how- 
ever, its  chief  function  appears  to  be  its  liability  to  become  in- 
fected. It  is  not  frequently  invaded  by  the  gonorrheal  organ- 
ism, but  this  accident  may  happen.  In  any  event  it  may  be 
necessary  to  differentiate  such  abscess  formation  from  pros- 
tatitis and  from  cystitis. 

There  is  another  possible  sequel  of  gonorrheal  urethritis, 
viz.,  ichio-rectal  abscess. 


94 


DIFFERENTIAL  BETWEEN  GONORRHEAL 


Prostatitis. 


Cystitis. 


Space  of  Retzius 
Abscess. 


Ischio-Rectal 

Abscess. 


History  of  Tumor. 


Negative. 


Marked  when  bo- 
wels move.  Vio- 
lent and  throb- 
bing. 


Tenesmus  usually 
absent.  Reten- 
tion common. 
Stream  dimin- 
ished. 


101  to  104. 


Frequency- of  mic- 
turition, most 
marked  at  night 


Negative. 


Negative. 


Perineal 
nence. 


promi' 


Pain. 


Pain  over  bladder. 
Burning,  con- 
stant. 


Marked  retro-sy  m- 
physeal  distress 


Disability. 
Tenesmus  always 
typically  pre- 
sent and  se- 
vere. Retention 
rare.  Stream 
normal. 


Tenesmus  absent. 
Retention    im- 
probable. 
Stream  normal. 


100  to  108. 


Temperature. 


101  to  104. 


Urinary  Symptoms. 
Negative. 


Most   marked    by 
day. 


LOCAL  PHYSICAL. 

Palpation. 


Pressure  pain  1  No  pressure  pain 
marked,  pros-  or  prostatic  en- 
tate  enlarged.     |     largement. 


Tender  ness  on 
deep  abdominal 
pressure. 


Exploratory  Puncture. 


Sero-sanguinous 
or  purulent. 


Gross  appearance 
normal.  No 
blood  or  album- 


Absent. 


Absent. 


LABORATORY  FINDINGS. 

Urine. 


Gross  appearance 
changed.  Tur- 
bid with  floccu- 
lent  masses. 
Blood  present  if 
acute.  (Albu- 
min due  to  pus) 


Normal.   No  albu- 
min or  blood. 


Over  perineum. 


Ten.ab.  Retention 
absent,  except 
under  very  ag- 
gravated condi- 
tions. Stream 
normal. 


100  to  103. 


Negative. 


Tenderness 
perineum. 


Generally      puru- 
lent. 


Normal.  No  albu- 
min or  blood. 


95, 


DIFFERENTIAL  BETWEEN  GONORRHEAL.— Continued. 


Prostatitis. 


Cystitis. 


Space  ofRetzius 
Abscess. 


If  acute  and  cys- 
tic, Sp.  Grav. 
1010  Alb.  in  ex- 
cess. Germs 
present.  (Exu- 
date) 


Negative. 


Irrigation  often 
helpful. 


Puncture  Fluid. 


Absent.  Absent. 


Drug  ADMiNisTR.vnoN. 


Positive. 


Negative. 


Mechanical  Treatmrnt. 
Negative. 


Irrigation   c  u  r  a 
tive. 


Ischio-Rectal. 
Abscess. 


Dense,  creamy 
fluid.  Sp.  Grav. 
1030.  Many 
cells.  Gonococci, 


Negative. 


Negative. 


CHAPTER  IX. 
THE  HEAD  AND  SPINE. 

Brain  lesions  are  so  frequently  associated  with  scalp 
lesions  and  scalp  lesions  with  those  of  the  skull,  that  it  is  worth 
while  to  draw  an  analogy  between  the  morphological  relations 
of  the  hard  and  soft  parts  of  the  entire  brain  covering. 

The  scalp  and  the  skull,  fortunately  for  the  sake  of  one's 
memory,  consist  of  three  analagous  concentric  shells.  There 
is  a  relatively  soft  sheet  externally  and  a  tough  brittle  sheet 
internally.  Between  these  two  corresponding  sheets  there  is 
a  soft  and  friable  layer. 

Brain  surgery  has  not  made  advances  in  the  past  five  years 
commensurate  with  that  of  other  more  popular  regions  of  the 
body.  Eighteen  years  ago  Weir  and  Seguin  were  just 
sufficiently  advanced  to  localize  a  cortical  cerebral  tumor.  They 
were  able  at  autopsy  to  verify  their  findings.  They  did  not, 
however,  feel  justified  in  advising  operation. 

By  clinical  experience  and  by  information  gained  through 
vivisectional  work  a  very  great  degree  of  accuracy  in  brain 
surgery  has  been  reached,  but  it  must  be  confessed  that  even 
the  surgery  of  the  hitherto  prohibited  chest  cavity  is  probably 
more  advanced  than  that  of  the  brain. 

It  is  not  that  the  brain  or  the  cord  ofifer  insurmountable 
technical  difficulties,  but  rather  that  in  from  80  to  90  per  cent, 
of  cases,  the  possibility  of  reaching  a  positive  differential  is 
denied  us.  Surgeons  do  not  yet  feel  justified  in  making  ex- 
ploratory incision  of  the  spine  or  cord  with  the  same  freedom 
that  they  do  in  the  case  of  the  abdomen.  This  is  partly  be- 
cause the  immediate  danger  is  greater,  and  partly  on  account 
of  the  difficulty  of  interpreting  and  correctly  judging  conditions 
after  exploration  is  made. 

There  is,  however,  a  small  number  of  reasonably  well 
determined  lesions  within  the  brain  case,  upon  which  a  satis- 
factorily certain  differential  can  be  made.  One  of  the  most 
common,  as  well  as  most  practical,  is  a  differential  between 
the  classical  causes  of  compression. 


*  DIFFERENTIAL  BETWEEN 


97 


Bone. 


Blood. 


Bugs. 


Body. 
(Foreign) 


History  of  Injury. 


Present. 


Onset  immediate. 


Normal. 


Present. 


Present  or  absent. 


Disease. 

Onset  slow  and  ir- 
regularly pro- 
gressive. 

Temperature. 


86  to  72  hours. 


100  to  102.      (Clo' 
absorption.) 


102  to  105.     (Tox- 
ins) 


Present. 


Immediate. 


Normal. 


Immediate     and 
continued. 


NERVOUS  SYMPTOMS. 

Unconsciousness. 

Immediate,  due  to 
concuss'n.  Vom- 
iting. Recov- 
ery. Localized 
convulsions  and 
unconsciousness 
within  variable 
time.  Depends 
on  rate  of  hem- 
orrhage. 


Delirium,  loss  of 
consciousness  in 
final  stage. 


Immediate. 


Exploratory  Incision. 


Spicules  of  inner 
table. 


Free  blood. 


An  exudate. 


Bullet  or  the  like* 


*  Note  that  these  all  begin  with  '"B" 

It  will  thus  be  seen  that  the  dififerential  between  these  four 
causes  of  compression  depends  practically  on  the  character  of 
the  onset  of  unconsciousness  and  upon  the  temperature. 

It  is  always  difficult  to  differentiate  the  conditions  and  find 
the  true  one  which  has  caused  a  person  to  be  unconscious. 
Among  the  many  possible  cerebral  causes  of  unconsciousness, 
there  are  four,  the  first  three  of  which  have  frequently  to  be 
differentiated.  As  presented  in  the  following-  columns,  the 
first  two  occur  synchronously  under  most  conditions,  that  is 
to  say,  the  second  cannot  be  present  without  a  certain  degree 


FISSURES. 


^7«»^< 


c.xs:of 


Fig.  18 

Shows  relation  of  fissures  to  surface.  Note  relation  of  Reid's  Base  Line  to. 
Inion.  Compare  position  of  proximal  end  of  Fissure  of  Rolando  with 
position  for  trephining  for  middle  Meningeal,  shown  in  Fig.  19.  This 
explains  symptoms  of  surgical  hemorrhage  as  given  in  differential. 

Rolando. — Draw  line  from  Root  of  Nose  to  Occipital  Protruberance  over 
the  convexity  of  the  head.  On  this  line  mark  ofif  point  .557  of  the 
distance  from  before  backward.  From  this,  a  line  is  projected,  run- 
ning downward  and  forward  '6%  inches  at  an  angle  of  67*^  to  the  pre- 
viously mentioned  line — this  represents  the  fissure  of  Rolando. 

Sylvius. — Draw  line  '[i^  inches  back  from  Extl.  Angular  Process,  ||  to. 
Reid's  Base  Line — Erect  a  quarter  inch  _L  to  this  and  from  the  tip  of 
this  J_  carry  a  line  up  and  back  to  meet  a  _|_  dropped  ^4  i"-  from  the 
Parietal  eminence — giving  Fissure  of  Sylvius. 

Parieto-Occipital  Fissurk: — By  prologing  Fissure  of  Sylvius  to  median, 
line. 


DIFFERENTIAL. 


99 


of  the  first.  Their  symptoms  are  differently  given  by  different 
authors,  and  they  are  well  known  to  overlap  and  interdigitate 
most  confusingly. 

The  first  and     the   third   are  always  synchronous.     The 
differential  referred  to  is  between,   old  friends. 


DIFFERENTIAL  BETWEEN 


Concussion. 


Compression. 


Contusion. 


Grand  Mal. 


Always  present. 


Onset  sudden. 


History  of  Injury. 

Always  present.      Absent. 

History  of  Disease. 


Very   frequently 
present. 


Onset  may  be  slow 


Onset  slow. 


Negative. 


Sign  of  regaining 
consciousness, 


Sphincters  may  be 
relaxed. 


96  to  99. 


Negative. 


Malformation. 


Negative. 


Vomiting. 


Not  frequent. 
Never  present 
after  brain  pres- 
sure is  well  de- 
veloped. 


Frequent. 


Bladder  and  Rectum. 

Typically  emptied 

Temperature. 


Emptied  only  in 
early  stage  if  at 
all. 


101  to  102. 


99  to  101. 


Pulse. 


Weak,  120;    irreg-'e^  «a 

ular,     deficient, i^\^^°S'  ^^'   'ys^^-  Same  as  m  com 
short,  compress-l     J^^'      bo^ndrng, 
ible. 


long  and  full. 


press  io  n,  but 
rises  to  100. 


Onset  accompani- 
ed by  aurae. 


Stigmata. 


Absent. 


Rarely  emptied. 


Normal. 


Normal. 


100 


DIFFERENTIAL  BETWEEN— Continued. 


Concussion. 


Compression. 


Contusion. 


Grand  Mal. 


Respiration. 


-Shallow,    sighing, 
'60. 


Sterterous,      puff- 
ing, 8  to  14. 


No    characteristic 
change. 


Sighing,  20. 


NERVOUS  SYMPTOMS. 

Central. 


TJ  n  consciousness 
incomplete.  Can 
be  roused. 


Often  present. 


Face     white     and 
wet. 


Pupils  react.  Un- 
equally irregu- 
lar. 


May  be  exaggerat- 
ed. 


U  n  consciousness 
absolute.  Can- 
not be  roused. 


U  n  consciousness 
incomplete,  but 
can  be  roused 
with  difficulty 
only. 


Convulsions. 


Absent,  except 
when  pressure 
very  high. 


Depends  on  posi- 
tion of  tear. 


GENERAL  PHYSICAL. 

Inspection. 


Face  red  and  dry. 


Face  red  and  dry. 


Superficial  Reflexes. 


Dilated.      Do  not 
react. 


Dilated.       Do  not 
react. 


Diminished  or  ab- 
sent. 


Deep  Reflexes. 

Exaggerated. 


U  n  consciousness 
complete.  Can- 
not be  roused. 


Present. 


Normal  color,  no 
sweat,  contor- 
tions frequent. 


Pupils  dilated. 


Diminished  or  ab- 
sent. 


These  represent  some  of  the  most  important  differential 
points.  So  great  is  the  variability  in  the  symptoms  presented 
by  these  lesions  that  just  exception  may  be  made  in  the  case  of 
almost  every  attempt  to  differentiate  them.  Authorities  differ 
widely  in  their  statements  as  to  the  symptoms,  it  being  impos- 
sible to  find  two  text  books  which  agree  on  every  point.  It 
would  be  easy  to  forecast  what  the  symptoms  shotild  be  in  any 
one  of  these  conditions,  if  a  thorough  understanding  of  the 
pathology  were  possible. 


CONCUSSION,  COMPRESSION,    CONTUSION.  101 

Brewer  states  that  contusion  is  always  associated  with 
concussion.  The  symptoms  of  concussion  appear  first  and 
cloak  those  of  the  more  serious  lesion.  His  few  pages  devoted 
to  these  subjects  render  them  clearer  than  chapters  of  other 
text  books. 

Concussion  is  like  shock  in  symptoms,  but  not  in  gross 
pathology.  It  is  characterized  probably  by  a  less  extensive 
degree  of  cerebral  anemia.  It  differs  from  shock  further  in  that 
it  is  complicated  by  symptoms  of  brain  tearing.  Pure  concus- 
sion, then,  is  a  hypothetical  lesion.  Did  it  exist,  it  could  prob- 
ably not  be  differentiated  from  the  apathetic  form  of  shock. 
It  is  due  either  to  atomic  or  molecular  upheavals,  if  such  divi- 
sions of  matter  exist.  In  a  measure  it  resembles  neuralgia  of 
peripheral  origin,  which  is  supposed  to  have  an  origin  in  mole- 
cular disturbance.  Practically,  however,  all  one  needs  to  re- 
member is  that  the  symptoms  of  shock  and  of  concussion  may 
be  virtually  one. 

Compression  is  a  somewhat  more  definite  lesion.  It  is 
very  easy  to  understand  that  although  hydraulic  pressure  nor- 
mally is  transmitted  equally  in  all  directions,  the  tightness  of 
the  falx  and  tentorium  membranes  must  considerably  retard 
the  equalization  of  this  pressure.  Compression  symptoms  de- 
pend, then,  partly  upon  the  position  of  the  pressure  producing 
lesion,  particularly  if  this  be  fluid.  They  depend  also  upon  the 
period  of  the  illness  at  which  the  patient  is  seen.  This,  of 
course,  is  true  of  all  diseases.  Symptoms  are  rarely  stationery, 
and,  for  this  reason,  it  is  utterly  impossible  to  give  a  dift'eren- 
tial  that  may  not  be  open  to  criticism,  because  it  is  very  difficult 
to  stipulate  the  exact  period  at  which  the  observations  recorded 
are  made. 

The  reflexes  of  the  eye  and  the  condition  of  the  vesical 
and  rectal  sphincters  afford  but  unsatisfactory  evidence  be- 
cause of  their  variability. 

Contusion. — This  symptom  is  usually  seen  as  a  sequel  of 
concussion.  The  unfortunate  subject  of  this  lesion  is  not  in- 
frequently driven  from  hospital  to  hospital  under  the  suspicion 
of  malignering.  This  is  not  the  fault  of  those  who  examine 
him,  but  because  the  symptoms  of  cerebral  irritation  are,  in 
their  early   stages  at  least,  indistinguishable  from  the  group 


102  SYMPTOMS  OF  CONTUSION. 

often  craftily  imitated  by  men  and  women  suffering  from 
hospitalism.  Where  10,000  useless  degenerates  are  turned 
aside  from  the  hospitals  and  prevented  from  preying  upon  the 
public,  one  also  is  turned  aside  who  has  the  real  symptoms 
of  cerebral  irritation. 

In  more  advanced  stages  the  symptoms  are  characteristic, 
but  even  then  the  victim  may  easily  be  mistaken  for  a  bad 
tempered  derelict.  This  is  important  to  remember  in  differen- 
tiating cerebral  irritation. 

Picture  an  old  "Bowery  skate"  who  has  come  into  the 
hospital  and  has  been  assigned  to  a  bed.  Unless  prevented,  he 
will  insist  on  wearing  his  ragged  coat.  He  is  indisposed  to  pull 
his  dilapidated  pants  off.  With  one  suspender  over  his 
shoulder  he  lies  on  the  comfortable  bed  in  a  typically  tetanoid 
position,  that  is  to  say,  with  all  the  joints  in  moderate  flexion. 
His  eyes  are  closed,  his  face  is  apathetic.  His  bowels  are  not 
lost  to  control,  and  his  urine  flows  normally.  He  resents  inter- 
ference with  an  oath.  Because  of  his  irritability,  he  is  shunned 
by  the  other  patients  who  regard  him  as  a  crank.  Unless  he  is 
carefully  watched,  he  will  empty  his  bowels  in  the  bed,  because 
it  appears  to  be  too  much  exertion  for  him  to  go  to  the  toilet. 
He  will  eat,  but  only  if  food  is  brought  to  him ;  he  will  not  go 
and  hunt  for  it.  In  short,  he  presents  a  typical  picture  of  an 
irritated  recluse  suffering  from  a  severe  "grouch." 

This  picture,  of  course,  is  that  of  a  mild  and  chronic  case. 
Cerebral  lesions,  causing  irritation,  may  be  so  profound  as  to 
be  unmistakable. 

BRAIN   HEMORRHAGE. 

This  may  conveniently  be  divided  into  two  types,  the 
medical  and  the  surgical.  The  medical  usually  occurs  from 
the  lenticulo-striate  artery  (Charcot's),  the  largest  branch  of 
the  middle  cerebral.  It  is  poorly  protected,  and  is  known  to 
undergo  atheromatous  change  of  an  advanced  type  early  in 
the  course  of  that  disease.  Its  walls  do  not  increase  propor- 
tionately in  strength  as  the  vessel  dilates  from  over  cerebration. 
It  is  consequently  dilated  and  is  apt  to  become  atheromatous 
in  men  of  profoundly  active  minds.  Osier  calls  pneumonia  the 
friend  of  the  aged.     Apoplexy  may  well  be  called  the  friend  of 


TREPHINE  AREAS, 


103 


the  thinker.  Unfortunately,  it  is  as  yet  beyond  the  pale  of 
surgical  intervention.  Medical  hemorrhage  is  more  common 
than  the  surgical  form. 


f}rOJn  CCff,se.tsr      i 


Fig.   19 


SOME  TREPHINE  AREAS. 


Reid's  Base  Line — Lower  margin  Orbit  to  External  Auditory  Meatus. 

Trephine  for  Middle  Meningeal. — 1>^  in.  above  Zygoma;  1>^  in.  back 
from  external  angular  process. 

Trephine  for  Brain  Abscess. — ^  in.  above  External  Audit.  Meatcus;— 
if  not  there,  IX  inches  behind  external  audit,  meatcus:  X  i^-  below 
R.  B.  L.     (Cerebellar  Abscess) 

Trephitie  for  Lateral  Sinus. — 1  inch  behind  Auditory  Meatus;  %  in. 
above  R.  B.  L. 


104 


SENSORI-MOTOR   AREA. 

Fic.   20 


V^^     VtA" 


H 


SigpT 


A/OTo 


r  Sriicn 


•      SoUNT> 

Fig.  21. 


POSITION  OF  THE  CENTERS.  lO.S 

Surgical   hemorrhage   generally  comes   from   the  anterior 
branch  of  the  middle  meningeal  artery.     Its  extent  is  deter- 
mined by  two  factors;  namely  by  the  degree  of  laceration  and 
by  the  position  of  the  wound.        Not  infrequently  the  middle 
meningeal  lies  in  somewhat  more  than  a  i8o  degree  channel 
on  the  skull  case.     This  amounts  virtually  to  a  canalization  of 
the  bone  by  the  vessel,  and  from  it  two  interesting  conclusions 
result.      First,   hemorrhage   must   take   place   from   an   artery 
which  is  enveloped  by  bone,  but  very  slowly,  if  at  all;  and 
second,  the  artery  must  be  injured  in   almost  every  case  of 
simple  linear  fracture  of  the  bone  across  its  course.     The  rela- 
tion of  the  dura  to  the  tear  is  also  a  determining  factor  in  blood 
extravasation.      Hemorrhage    will   naturally   take    place    very 
much   more   rapidly   central,   rather   than   peripheral,   to   this, 
tough  membrane.    Cases  of  peripheral  dural  bleeding  have  been 
known  to  occupy  a  week  or  more  before  symptoms  became 
marked.     This  is  to  be  explained  by  the  difficulty  which  the 
blood  experiences  under  the  limited  cardiac  pressure  in  tearing 
the  dura  from  the  bone. 

The  home-made  method  of  remembering  the  position  of 
the  centers  in  a  sensory  motor  area  is  shown  in  the  accompany- 
ing figure.  It  demonstrates  the  body  of  a  puppet  upside  down, 
which  is  the  position  taken  by  the  centers,  as  shown  by  the 
companion  figure.  It  demonstrates  further  that  just  posterior 
to  the  fissure  the  sensory  and  the  moior  areas  overlap  each 
other.  This  little  scheme  has  long  been  used  by  Dr.  Robert  H. 
Dawbarn  in  demonstrating  his  lectures  on  the  brain. 

The  position  of  the  anterior  branch  of  the  middle  men- 
mgeal  is  such  that  the  first  symptoms,  after  the  recovery  of 
the  unconsciousness  produced  by  the  primary  concussion, 
should,  as  shown  by  the  puppets  in  the  Figure  be  motor  irrita- 
bility of    the  face  and  arms. 

BRAIN  AND  MEMBRANE  INFLAMMATIONS. 

There  is  no  more  favorable  location  for  the  growth  of 
bacteria  than  within  the  brain  case.  There  are  various  ways 
by  which  these  germs  obtain  ingress.  It  may  be  convenient  to., 
use  Sub-Scheme  III  to  give  the  causes  of  intra-cranial  infection. 
It  may  be  brought  about  by  T.  I.  D.  M.  of  the  parts. 

Of  tumors  situated  externally,  epitheliomata  may  be  taken- 


106  CONTINUITY  AND  CONTIGUITY. 

as  representative.  These,  as  nutritional  advantages  decrease, 
break  down  and  become  infected.  The  drainage  from  such 
ulcerating  areas  is  apt  to  be  by  one  of  the  Emissory  Veins. 
This  is  more  apt  to  be  the  case  if  the  lesion  under  consideration 
is  located  upon  the  scalp,  although  the  face,  as  show^n  by  the 
figure,  is  not  a  region  exempt  from  danger.  Suppose  drain- 
age of  the  epithelioma  to  take  place  via  the  ophthalmic 
vein.  It  terminates  in  the  cavernous  sinus,  and  from  this  great 
blood  lake  infection  travels  into  the  brain  by  contiguity  of 
tissue.      (See  Fig.  13) 

It  is  important  to  know  the  difference  between  travelling 
by  continuity  and  contiguity  of  tissue.  It  would  be  easy  to 
understand  the  terms  if  the  words  "of  tissue"  were  usually 
used,  but  they  are  not.  If  an  inflammatory  process  begins  in 
the  stomach,  as  an  ulcer  and  an  abscess  developes  in  the  con- 
tiguous lobe  of  the  liver,  that  infection  is  said  to  have  reached 
its  destination  by  contiguity.  The  tissues  were  near  to  each 
other,  but  they  were  not  continuous.  First,  there  were  stomach 
?ells,  then  interval  connective  tissue  cells,  then  liver  cells. 

If,  however,  an  abscess  had  formed  in  the  wall  of  the 
stomach,  those  products  would  have  reached  their  destination 
by  so  called  "continuity  of  tissue,"  because  they  never  were 
obliged  to  pass  out  of  the  stomach  wall. 

Consequently,  by  contiguity,  a  panencephalitis  might  be 
established  in  the  case  of  the  supposed  ulcerated  epithelioma. 

Sarcoma  of  the  Antrum  is  an  example  of  a  tumor  in  the 
wall  of  the  brain  case,  which,  on  breaking  down,  may  cause 
panencephalitis,  localized  intra-cranial  abscess,  or  any  form  of 
inflammatory  change. 

Tumors  on  the  inner  wall  of  the  brain  case,  which  cause 
intra-cranial  inflammation,  are  rare. 

External  Injuries. — Almost  any  injury  which  becomes  in- 
fected, and  which  is  situated  in  the  neighborhood  of  an  emis- 
sory vein,  may  cause  the  lesion  under  consideration. 

Fractures  are  the  next  possibilities  to  consider,  and  after 
injuries  come  the  diseases. 

Lupus.  This  disease  is  prone  to  ulceration,  and  the  man- 
ner of  infection  from  it  may  be  similar  to  that  of  epithelioma. 

Otitis   Media   often   affords   an   admirable    illustration   of 


CEREBRAL  ABSCESS.  107 

how  infections  travel  by  contiguity  of  tissue.  From  the  middle 
ear,  as  has  already  been  noted,  the  agents  travel  to  the  mastoid, 
thence  to  tlie  lateral  sinus,  producing  typical  phlebitis  of  the 
internal  jugular;  thence,  if  the  patient  lives,  to  the  dura,  pro- 
ducing pachymeningitis  ;  thence  to  the  pia  (always  supposing 
the  patient  to  stand  it),  producing  lepto-meningitis  ;  thence  to 
the  cortex,  producing  cortical  abscess ;  thence  to  the  enceph- 
alon,  producing  pan-encephalitis. 

Cerebral  Abscess,  then,  may  arise  in  a  variety  of  dififerent 
ways.  It  is  not  unlike  abscesses  elsewhere.  It,  therefore,  pos- 
seses  the  general  characteristic  that  it  may  be  due  to  a  pure 
or  a  mixed  culture  infection. 

The  best  example  of  pure  culture  cerebral  abscess  is  the 
tubercular.  About  this  abscess  an  interesting  point  of  dif- 
ference has  arisen.  The  chronic,  slowly  developing,  often  mul- 
tiple, frequently  secondary,  pure  culture  tuberculous  abscess 
causes  typically  a  sub-normal  temperature.  Its  antithesis,  the 
single,  acute,  rapidly  growing  mixed  infection  abscess  which 
bears  no  practical  relation  to  the  tuberculous  form  at  all,  cer- 
tainly in  its  early  stages,  is  characterized  by  a  temperature  of 
from  103  to  105. 

Park  states  that  the  temperature  when  raised  is  in  pro- 
portion to  the  degree  of  meningeal  involvement.  He  says  fur- 
ther that  a  particular  characteristic  of  the  cerebral  abscess  is 
its  tendency  to  form  about  itself  a  pyophylactic  membrane  by 
which  the  abscess  becomes  entirely  capsulated.  In  fact  unless 
this  membrane  forms,  the  patient  is  almost  certain  to  succvimb 
in  the  acute  stages  of  the  abscess.  Thus,  "walling  off"  is  of 
vital  importance  in  the  brain. 

It  is  not  known  why  abscess  tends  to  produce  a  sub-normal 
temperature.  If  it  were  a  usual  accompaniment  of  intra-cere- 
bral  pressure,  one  would  expect  to  find  it  a  manifestation  of 
tumor ;  but  such  is  not  the  case.  There  can  be  little  doubt  that 
whatever  the  cause  of  the  subnormal  temperature  acute  ab- 
scesses, which  undergo  the  encapsulation  process,  become  prac- 
tically the  same  as  pure  culture  tubercle  abscess.  They  are  in 
other  words  "cold"  and  should  .naturally  not  be  expected  to 
produce  the  symptom  of  elevated  temperature.  The  conclusion 
then  is,  that  although  probably  a  number  of  cases  of  abscess 


108 


CEREBRAL  DIFFERENTIALS. 


which  in  the  past  were  described  as  mixed  culture  abscesses, 
have  in  reaHty  been  pure  culture  tubercular  formations.  In 
this  case,  a  subnormal  temperature  has  erroneously  been  as- 
cribed to  them. 

One  of  the  most  frequently  asked  as  well  as  the  most  con- 
fusing differentials,  is  between  cerebral  tumor,  abscess,  tuber- 
culous meningitis  and  typhoid.  It  is  obviously  of  the  gravest 
importance  for  the  patient  that  correct  conclusions  should  be 
reached  early  because  of  the  fundamental  difference  in  the 
modes  of  treatment.  In  this  differential,  as  in  others,  no  at- 
tempt is  made  to  give  all  the  smallest  details  which  are  in- 
tended to  be  filled  in  by  the  reader.  Furthermore,  here  as  else- 
where, it  is  not  possible  to  be  dogmatic  without  opening  a  free 
path  for  justly  unfavorable  criticism.  Whatever  flavor  of  dog- 
matism is  present  has  been  extracted  from  the  most  recent 
text  books  on  the  subject. 

DIFFERENTIAL  BETWEEN 


Cerebral  Tumor. 


Cerebral 
Abscess. 


Tuberculous 
Meningitis. 


Typhoid  Fever. 


History  of  Injury. 


Not  rare,  especi- 
ally in  sarcoma- 
ta. 


Onset  fairly  rapid 


Before  20  if  tuber- 
cle; 20  to  40  if 
sarcoma. 


Very  severe.  Con- 
stant. Some- 
times located 
over  lesion. 
Worse  in  early 
morning. 


Frequently  fol- 
lows fracture 
of  skull. 


Absent. 


Disease. 


Onset  slow.   Chill. 


Onset  slow.    T.B. 
elsewhere. 


Age. 


Active  adult  life. 


Childhood. 


Pain. 


Severe.      May   be 
localized. 


Often   worse  at 
night. 


Absent. 


Onset  slow.  Anor- 
exia. Nosebleed 
common. 


15  to  30. 


Headache  often 
absent. 


109 


DIFFERENTIAL  BETWEEN.— Continued. 


Cerebral  Tumor 


Cerebral  Abscess 


Tuberculous 
Meningitis. 


Typhoid  Fever 


Disability. 


Depends  on  posi- 
tioi:.  May  be 
anywhere. 


If  protectile  or  dis- 
tinctly "cere- 
bral" in  type 
very  important. 


Because  of  fre- 
quency in  cere- 
bellum, often 
disturbances  of 
gait. 


Stiff  neck. 


Vomiting. 

Not    infrequent,  TVT  ^     u         .     •  ^• 
but  nausea  rare,  r""^  characteristic 


Negative. 


Normal. 


Strong,   50,    regu- 
lar. 


Bladder  and  Rectum. 
Negative. 

Temperature 
96.5  to  100. 


May  be  secondary! 
to  enteric  T.  B. 
If  so,  diarrhea. 


100  to  102.    Even- 
ing rise. 


Pulse. 


Strong.    40   to  50, 
regular. 


Strong,    60  to  70, 
regular. 


NERVOUS  SYMPTOMS. 

Vertigo. 


Not  common  un-l 
less   in  cerebel-  Very  common 
lum. 


Absent. 
Delirium. 


Late,  if  at  all. 


If  present,    abso- 
lute. 


Usually      general 
and  early. 


Apt  to  be  earlier. 


Early. 


Unconsciousness. 
Absolute.  Less  profound. 

Convulsions.  - 

Not  so  common  as  r^ 
in  tumor.  Common. 


Dysalimentation. 


If  present,  of  dis- 
tinctly "gastric ' 
type. 


Constipation      o  r 
diarrhea. 


100  to  102.5.  "Step- 
ladder". 


Weak,  100  to  110, 
may  be  irregu- 
lar. 


Absent,  except 
from  gut  or  due 
to  weakness. 


Early,  late  or  ab- 
sent. 


Less  profound. 
Often  intermit- 
tent. 


Very  rare. 


110 


DIFFERENTIAL  BETWEEN.— Continued. 


Cerkbral  Tumor 


Cerebral  Abscess 


Tuberculous 
Meningitis. 


Typhoid  Fever 


Amnesic  Aphasia. 


Word-  deafness, 
common. 


Rare. 


Word  -  blindness, 
common. 


Often  cannot 
write.  (Second 
or  third  left 
frontal) 


Frequently     pres- 
ent. 


Not  so  common. 


Absent. 


If  in  tempero- 
sphenoidal, 
common. 


Motor  Aphasia. 
Absent. 


Alexia. 


Less  common. 


Absent. 


Agraphia. 


Rare. 


Absent. 


Absent. 


Absent. 


Absent. 


Absent. 


Apraxia. 
(Loss  OF  Perception  of  Objects) 


Occasionally  pres- 
ent. 


Absent. 
Paresis  or  Palsies. 


Frequent. 


Optic  neuritis 
common  and  of- 
ten double. 


Occasional. 


Not  so  common 
and  apt  to  be 
sinele. 


Absent. 
Special  Sense. 
Absent. 


Absent. 


Absent. 


Absent. 


LOCAL  PHYSICAL. 

Palpation. 


Negative. 


Very  rarely  local 
tenderness. 


Occasional  local 
increase  in  tem- 
perature. 


Not  infrequently 
local  tenderness 


Negative. 
Percussion. 
Absent. 


Negative. 


Absent. 


Ill 


DIFFERENTIAL  BETWEEN— Continued. 


Cerebral  Tumor 


Cerebral  Abscess 


Tuberculous 

Meningitis. 


Typhoid.  Fever 


Exploratory  Incision. 


Found  to  be  oper- 
able in  only  5  to 
10%  of  cases. 


Unaltered. 


In  temporo-sphen- 
oidal  lobe  or  ce- 
rebellum. Lo- 
calized pus. 


Pin-point  tuber- 
cles on  mem- 
branes. Exu- 
date. 


Negative. 


Negative. 


BLOOD. 

Leucocytosis. 

10,000  to  15,000.     I  9000. 

WiDAL  AND  Other  Tests. 

XT       i-  Positive  to  tuber-; 

^^S^^'^^-  I      culin.  I 

Effect  of  K.  I. 


5000 


Positive  to  Widal. 


If  gumma,   mark-  Negative 


ed. 


Negative. 


Negative. 


It  will  thus  clearly  be  seen  that  a  differential  between  these 
four  diseases,  particularly  if  they  are  taken  at  a  reasonably 
early  period  of  their  development,  is  extremely  difficult.  The- 
value  of  the  laboratory  findings  cannot  be  over  estimated,  for 
clinically  there  may  be  a  very  grave  and  discouraging  absence 
of  facts. 


THE  SPINE. 

If  difiticulty  has  been  experienced  in  localizing  cerebral  in- 
juries, it  has  been  much  greater  in  the  case  of  the  cord.  This 
is  obviously  because  the  cord  is  concerned  only  with  reflex  ac- 
tion and  with  transmission.  These  functions,  are  extremely 
difficult  to  localize  with  any  degree  of  accuracy.  Precisely 
similar  lesions  arise  in  the  cord  as  in  the  brain  and  their  causes 
are  in  a  measure  identical  with  those  affecting  the  higher  cen- 
ters. It  often  becomes  necessary  to  establish  a  differential 
between  a  supposed  case  of  spinal  hemorrhage,  of  bone  pres- 


112 


SPINAL  DIFFERENTIALS. 


sure  of  transverse  lesion  of  the  cord,  or  of  certain  very  rapidly 
grov^fing  tumors.  In  theory  this  may  be  possible,  but  in  prac- 
tice most  unfortunately  it  is  too  true  that  a  positive  conclusion 
can  be  reached  only  after  exploratory  incision.  There  are, 
however,  points  of  academic  interest  and  these  have  been  ar- 
ranged as  concisely  as  conflicting  opinions  of  authorities  allow. 

DIFFERENTIAL  BETWEEN 


Spinal 
Hemorrhage. 


Bone  Pressure. 


Transverse  Mye- 
litis. 
(Traumatic) 


Sarcoma. 


History  of  Injury. 


Always  present. 


Always  present. 


Always  present. 


History  of  Disease. 


Onset    may    be 
slow.       Symp- 
toms increase. 

Onset  immediate. 
Symptoms    sta- 
tionary. 

Same. 

Previous  Disease. 

Atheroma. 

Negative. 

Negative. 

Sex. 

Negative. 

Negative. 

Negative. 

Temperature. 

100  to  102. 

Normal. 

98  to  100. 

Paresis  and  Paralysis. 

Appear  late.  Mod- 
erately slow  in- 

Immediate. 

Immediate. 

crease. 

Absent. 


Relatively  very 
slow.  Symp- 
toms increase. 


Involvement  else- 
where. 


30  to  40.  (McCosh) 


Normal. 


Appear  late.   Slow 
increase. 


LOCAL  PHYSICAL. 

Inspection. 


Often  irregularity 
of  spine. 


Same. 


Same. 


Negative. 


LAMINECTOMY.  113 

It  will  be  seen  that  there  are  very  few  available  data  upon 
which  to  base  a  differential  of  the  spinal  lesions.  Brewer  says 
that  a  recognition  of  extra-dural  and  subdural  hemorrhage  is 
surgically  unimportant  even  if  they  do  occur  unassociated  with 
fracture  or  dislocation,  because  they  cannot  be  clinically  recog- 
nized. 

Laminectomy  is  the  term  used  to  designate  the  technic 
which  is  used  in  reaching  the  cord.  The  danger  of  this  opera- 
tion increases  very  rapidly  as  it  approaches  the  brain.  The 
chief  matter  of  importance  concerning  it  is  that  if  indicated  at 
all  it  should  be  performed  immediately.  It  is  interesting  that 
this  rule,  which  was  formerly  supposed  to  hold  good  for  in- 
jured nerves,  has  recently  been  demonstrated,  as  already  cited, 
to  be  fallacious.  (See  chapter  on  nerves.)  That  this  does  not 
hold  true  in  the  case  of  the  cord  is  undoubted,  for  degenerative 
processes  of  a  destructive  nature  are  pretty  definitely  proven  to 
be  well  under  way  thirty-six  to  forty-eight  hours  after  the  cord 
has  been  injured,  and  by  some  authorities  before  then. 


CHAPTER  X. 
THORAX. 


Fig.  23 

The  Compleinental  Sinus 
is  shown  as  the  higher  of  the 
two  areas  mapped  out  on  the 
lower  region  of  the  Thorax. 
It  is  that  space  intervening 
between  the  lower  border  of 
the  lung  and  the  line  of  Re- 
flection of  the  Pleura  and  is 
filled  with  Pus  in  non-en- 
cysted empyema. 

The  Costo  Phrenic  Sinus 
lies  just  below  the  comple- 
mental  and  its  inner  and 
outer  boundaries  are  formed 
respectively  by  Diaphragm 
and  Thoracic  wall.  This 
Sinus  is  the  seat  of  Costo 
Phrenic  Abscess. 

The  following  table,  in  part 
compiled  according  to  Hunt- 
ington will  be  found  useful. 


J>.^^r^,^._^' 


complkme-n  tal  and  supplemental 

Sinus. 

Comply- 
Lower  Pleural  menial 
Line.                    Limit.                  Lunr/.  Sinus. 

Sternal—           Upper  VII.  Kil),  Upper  VI.  2  ciu. 

Paraslerual — Middle  VII.    "     Lower  VI.  20111. 

Mammary —     Lower   VII.    •'     Ui^iiier  VII.  2  cm; 

Axillary—                        IX.    "     Lower  VII.  Gem. 

Vertebral—                    XII.    "           "      XI.  2.53  cm. 


This  shows  a  longitudiual  elevation 
through  the  centre  of  Fig.  22.  Con- 
sult Deaver's  anatomy  for  further 
data. 


Note  thai  the  greatest  depth  of  the 
Complemental  Sinus  is  in  the  axillary 
line. 

The  Costo  Phrenic  Sinus  naturally 
is  bounded  above  by  the  Lower  Pleural  limit  and  below  by  the  attachment  of 
the  diaphragm  to  the  Ribs  and  Rib-Cartilages,  (See  cut  of  diaphragm  in 
chapter  on  hernia. ) 


DIVERTICULAE.  115 

The  surgery  of  the  thorax  has  been  stimulated  very  much 
by  the  perfection  of  methods  for  artificial  respiration  pending 
the  opening  of  the  chest  cavity.  Prominent  among  these  is 
one  devised  by  Matas  of  New  Orleans.  It  is  so  constructed 
that  it  automatically  supplies  the  required  amount  of  air.  This 
obviates  the  danger  of  the  variable  dosage  which  the  excite- 
ment of  a  major  operation  was  almost  certain  to  engender 
when  the  old  instruments  were  used. 

The  Esophagus,  partly  because  of  its  great  importance  and 
its  unfortunate  liability  to  disease,  besides  the  fortunate  fact, 
that  although  passing  through  the  thorax,  its  whole  extent  can 
be  reached  without  opening  that  cavity,  has  been  the  object 
of  more  surgical  intervention  than  any  other  organ  in  the  chest. 

One  of  the  most  interesting  lesions  which  can  befall  this 
tube  is  the  formation  in  it  of  Diverticulae.  The  causes  of  these 
diverticulae  can  easily  be  enumerated  by  reference  to  Sub- 
scheme  III.  They  arise  as  a  result  of  twelve  possible  condi- 
tions, viz. — Tumor,  Injury,  Disease  or  Malformation  within  the 
lumen,  in  the  wall  of  the  lumen  and  without  the  lumen,  or  in 
other  words  in  twelve  possible  positions.  The  accompanying 
radiogram,  which  was  recently  made  by  Dr.  Cole  at  Roosevelt 
Hospital,  shows  the  nature  of  these  diverticulae  very  beauti- 
full}^  The  outline  was  made  clear  by  causing  the  patient  to 
swallow  about  two  ounces  of  carbonate  of  bismuth.  The 
esophagus,  on  account  of  its  being,  collapsed  antero-pos- 
teriorly,  appears  in  this  side  view  as  a  line. 

These  diverticulae  are  often  the  result  of  stricture. 

Dunham  has  recently  shown  that  almost  every  stricture 
which  is  of  such  nature  that  the  patient  is  not  prevented  by  it 
from  swallowing  water,  can  be  passed  by  allowing  a  thread  to 
float  in  the  water  and  by  then  swallowing  the  liquid  and  the 
line.  In  strictures  of  the  deep  esophagus,  which  are  beyond 
the  reach  of  external  esophagotomy,  and  as  a  preparator}/-  to 
Abbe's  Fish  Line  Treatment,  this  demonstration  is  of  great 
importance. 

The  Italians  have  been  the  pioneers  in  Cardiorrhaphy.  As- 
tonishing success  has  met  efforts  to  suture  the  heart  wall.  It 
depends  upon  the  introduction  of  interrupted  sutures  which  are 
ticfl  duriny  diastole. 


116 


ESOPHAGUS. 


^^O/D  BOA/£ 


ESOPHAGUS 


Fig.  24 


ESOPHAGEAL  DIVERTICULUM. 
(author's  case) 

Given  off  opposite  the  6th  cervical  vertebra.     (The  patient  coughed 
up  bismuth  for  two  weeks  after  this  radiogram  w^as  made.) 


TREATMENT  OF  EMPYEMA.  117 

Of  operations  which  necessitate  a  trans-pleural  route,  by 
far  the  most  frequent  are  those  for  the  relief  of  empyema. 
They  may  be  enumerated  as  follows:  (i)  Paracentesis,  (2) 
Resection  of  One  or  More  Ribs,  (3)  Estlander's  Operation,  (4) 
Schede's  Operation.  (This  last  might  be  spelled  "Shady"  for  it 
is  highly  doubtful  if  the  patient  survive  it),  (5)  Fowler's  Oper- 
ation. 

If  the  collection  of  fluid  in  the  pleura  be  localized  and  of 
such  extent  as  to  produce  a  bulging  ;•  a  condition  uncommon 
but  not  by  any  means  unknown,  the  needle  should,  after  most 
scrupulous  sterilization,  be  driven  in  over  the  most  prominent 
part  of  the  swelling.  If,  however,  as  is  more  frequently  the 
case,  the  exudate  is  not  loculated.  a  point  of  election  for  para- 
centesis is  just  below  the  scapula.  This  of  course  is  a  very 
movable  point,  but  it  is  usually  understood  that  the  arm  is  in 
a  position  past  full  abduction  from  the  body.  This  raises  the 
lower  scapular  angle  somewhat  and  carries  it  toward  the  axilla. 
The  needle  should  not  enter  lower  than  the  eighth  intercostal 
space,  and  when  it  is  withdrawn,  a  piece  of  zinc  oxide  adhesive 
plaster  should  be  clapped  over  the  wound  before  the  patient 
has  time  to  suck  air  in  through  it  by  making  a  respiratory 
effort. 

Now  suppose  the  pumped  out  fluid  to  have  been  a  simple 
straw-colored  liquid,  which  is  shown  by  laboratory  examina- 
tion, to  have  the  characteristics  of  an  exudate.  This  treatment 
will,  in  a  very  large  percentage  of  cases,  be  curative.  Occa- 
sionally, however,  either  because  of  infection  introduced  at  the 
time  of  operation,  or  because  of  a  contamination  of  the  exudate 
through  internal  sources,  the  patient's  condition  will  not  im- 
prove except  in  so  far- as  he  becomes  more  comfortable  at  once 
from  the  relief  of  pressure.  The  temperature,  in-stead  of  re- 
maining normal  or  falling  from  the  slight  rise  which  occasion- 
ally accompanies  simple  pleuritic  exudation,  either  maintains 
that  slight  rise  regularly,  or  else  creeps  slowly  upward.  What 
is  to  be  done  in  the  face  of  these  conditions? 

Obviously  drainage  is  indicated.  Some  very  excellent  au- 
thorities have  said  that  adequate  drainage  is  to  be  had  through 
an  intercostal  space.  Dr.  A.  A.  Moore  has  devised  an  ingen- 
ious little  instrument  for  so  draining  these  pus  cavities,  partic- 


118  ESTLANDER'S  TECHNIC. 

ularly  in  little  children.  The  general  consensus  of  opinion, 
however,  is  that  it  is  better  surgery  in  every  case  to  resect  a 
rib,  rather  than  to  attempt  intercostal  drainage.  Ribs  regen- 
erate very  rapidly  and,  the  resection  entails  a  remarkably  small 
amount  of  shock.  On  a  "stiff"  it  is  demonstrably  impossible  to 
do  a  sub-periostial  resection,  but  this  is  simply  because  the 
membrane  in  the  "stiff"  is  normal.  In  the  case  of  a  chronic 
empyema,  however,  the  periostium  is  very  apt  to  have  become 
somewhat  thickened  on  account  of  contiguous  productive  in- 
flammatory change.  The  section  of  rib,  consequently,  in  these 
cases,  shells  out  with  comparative  ease  from  its  enveloping 
membrane.  The  intercostal  vessels  and  nerve,  below,  are  not 
seen  if  the  periostium  be  split  directly  over  the  anterior  long 
axis  of  the  bone,  nor  are  the  smaller  vessels,  which  are  located 
at  the  upper  margin. 

Now  suppose  the  rib  resection  and  the  introduction  of  the 
usual  drainage  tube  to  have  failed.  What  is  the  next  step  to 
be  taken?  Obviously  it  is  necessary  to  establish  freer  drainage. 
The  condition  will  now  have  become  decidedly  chronic,  a 
greater  or  lesser  area  of  the  lung  having  retracted.  The  me- 
chanics of  the  proposition  therefore  become  simple.  A  con- 
stantly discharging  abscess  is  in  one  respect  like  nephritis  in 
that  the  body  in  each  condition  loses  highly  nutritive  albumin- 
ous fluids.  The  cavity  has  to  be  obliterated,  in  order  to  stop 
this  steady  drain  of  pus.  It  resolves  itself  into  either  bringing 
the  lung  out  to  meet  the  chest  cavity  or  of  dropping  the  chest 
wall  upon  the  permanently  collapsed  lung.  Obviously  it  is  bet- 
ter for  the  patient  if  the  lung  can  be  forced  out,  but  this  cannot 
be  done  in  all  cases. 

Estlander's  Operation  is  based  upon  an  acknowledgment 
of  defeat.  It  is  therefore  not  indicated  until  every  means,  such 
as  blowing  water  into  James'  Bottles  and  other  attempts  at  pro- 
ducing artificial  emphysema  have  been  tried.  Furthermore,  it 
is  not  likely  that  any  serious  attempt  to  collapse  the  chest  wall 
will  in  future  be  made  until  Fowler's  technic,  shortly  to  be 
spoken  of,  has  been  tried.  If  employed  as  thoroughly  as  is  rec- 
ommended by  its  distinguished  inventor,  there  must  be  very 
few  cases  in  which  it  will  fail  to  obviate  the  necessity  of  doing 
either  an  Estlander  or  a  Schede.     Suppose,  however,  Fowler's 


FOWLER'S  TECHNIC.  119 

technic  to  have  been  unsuccessfully  employed.  One  should  not 
at  this  stage  think  of  doing  a  Schede,  but  would  naturally  turn 
to  the  more  conservative  Estlander  technic.  He  advises 
(Brewer)  "the  removal  of  portions  of  several  ribs  according  to 
the  size  and  shape  of  the  underlying  cavity,  but  without  dis- 
turbing the  thickened  parietal  pleura." 

Schede's  Operation  (Brewer)  "consists  not  only  of  remov- 
ing the  ribs  but  also  the  parietal  pleura.  He  advises  'a  large  U 
shaped  incision,  beginning  near  the  junction  of  the  second  rib 
and  costal  cartilage,  extending  downward  and  backward  to  the 
tenth  rib,  then  upward  to  the  axillary  border  of  the  scapula.'  " 

Fowler's  Operation.  It  was  noted  some  time  ago  that  if, 
during  the  execution  of  one  of  these  throracoplastic  operations, 
the  visceral  pleura  was  cut,  the  lung  promptly  expanded  be- 
neath it,  so  that  the  simple  line  of  incision  could,  as  one 
watched  it,  be  seen  to  develop  into  an  opening  shaped  like  a 
bi-convex  lens.  It  must  be  remembered  that  after  the  establish- 
ment of  chronic  empyema,  the  visceral  pleura  has  promptly 
lost  all  its  delicate  physiological  functions  and,  because  of  its 
extreme  thickness  (sometimes  amounting  to  as  much  as  a  quar- 
ter centimeter)  has  begun  to  act  as  an  ever  tightening  con- 
strictor around  the  lung.  The  evil  effects  of  a  productively  in- 
flamed capsule  of  any  organ  cannot  be  overestimated ;  its 
agency  in  producing  lesions  of  the  kidney  will  be  spoken  of 
later. 

Cutting  the  blanket-like  pleura  was  destined  to  afford  re- 
lief of  a  measurable  but  inconstant  type.  The  technic  some- 
what resembled  the  subcutaneous  section  of  the  fascial  bands 
in  Dupuytren's  contracture,  which,  although  giving  temporary 
relief,  eventually  made  the  contracture  worse  by  the  subsequent 
increase  of  the  scar  tissue. 

Fowler  was  the  first  to  note  that  the  treatment  of  the 
pleura  should  be  the  same  as  the  treatment  of  Dupuytren's 
fascia,  viz. — that  it  should  be  removed  as  entirely  as  possible. 
He  therefore  advised  that  it  be  freely  incised  and  ripped  from 
the  lungs.  Obviously  this  should  be  done  early,  before  dry 
productive  inflammatory  (sclerotic)  changes  have  taken  place 
in  the  lung.     After  the  unfortunate  establishment  of  this  con- 


130 


MALIGNANT  DISEASE  OF  BREAST. 


dition,  there  is  no  relief  for,  nor  means  of  obliteration  of  the 
pus  cavity,  save  by  dropping  the  chest  wall  in  upon  it  as  pro- 
posed by  Schede. 


(2crom,o 


n. 


^a  e.  j  <2; 


Fig.  25 


,,7*       Tnamma 


This  is  an  adaptation  from  a  most  beautiful  cut  in  Eisendrath's 
Clinical  Anatomy.  It  shows  the  breast  quadrants  and  their 
lymphatic  drainage.  It  also  shows  the  very  important  rela- 
tions of  the  internal  mammary  artery. 

(Used  by  courtesy  of  De.  Eisendrath) 


THE  BREAST. 

Since  a  small  fraction  over  one-half  of  all  favorable  cases 
of  carcinoma  of  the  breast  can  be  permanently  freed  from  the 
disease,  it  is  indeed  a  pity  that  more  do  not  reach  the  surgeon. 

An    eminent    authority    has    divided    women    into    three 


DEGENERATION  OF  BENIGN  GROWTHS.  121 

classes.  Forty-five  per  cent,  of  them  are  so  frightened  at  the 
possibility  of  having-  a  tumor  in  their  breast  that  they  are  per- 
petually running  to  their  physician,  or  at  least  to  the  person 
who  poses  as  such — for  confirmation  or  refutation  of  their  sus- 
picions. 

Another  forty-five  per  cent,  are  so  badly  frightened  that 
when  they  find  a  tumor  in  their  breast,  they  conceal  it  from 
everybody  and  not  a  soul  knows  of  it  until  it  is  a  rotten  mass 
heralded  by  its  stench. 

The  remaining  ten  per  cent,  are  sensible  about  the  matter. 
Immediately  on  discovering  a  small  tumor  they  put  themselves 
under  the  care  of  a  competent  surgeon. 

Of  the  first  class,  almost  the  entire  number,  because  of 
their  dread  of  the  knife  and  their  willingness  to  submit  to  every 
"ism"  and  "no-knife  treatment,"  fall  in  discouragingly  great 
numbers  into  the  hands  of  the  charletan  and  of  the  ignorant 
but  well  meaning  practitioner  of  "isms."  Thus  it  is  that  prob- 
ably not  over  twenty  per  cent,  of  tumors  of  the  breast  of  a 
malignant  character  are  ever  subjected  to  suitable  treatment. 

So  hazy  is  the  border  line  between  an  adenoma  and  a  car- 
cinoma of  an  inactive  type,  that  it  is  impossible  to  say,  when 
the  one  may  fade  into  the  other.  The  changing  of  a  benign  into 
a  malignant  growth  may  be  likened  to  the  peeling  off  from  a 
sweating  hand  of  a  pair  of  moist  kid  gloves.  The  fingers  turn- 
ing inside  out,  reverse  their  direction.  That  is  all,  from  mor- 
phological evidences  in  any  event,  which  takes  place  when  in 
a  wart  or  mole,  the  fingers  of  which  have  been  extended  toward 
the  surface  and  engaged  in  no  malevolent  work,  some  unknown 
agent  suddenly  reverses  them  and  they  reach  out  hungrily  and 
malignantly  into  the  subjacent  tissue.  So  subtile  is  this  change 
in  these  most  simple,  superficial  little  growths  that  Keen  has 
gone  so  far  as  to  counsel  the  removal  of  every  wart  and  mole 
from  one's  body.  If  this  be  advised  on  the  opinion  of  so  high 
an  authority,  how  great  indeed  must  be  the  danger  to  which 
we  are  all  exposed  through  these  apparently  harmless  but  very 
common  growths.  Furthermore,  how  much  greater  must  be 
the  danger  of  malignant  degeneration  taking  place  in  the  more 
complicated,  more  vascular  and  less  freely  observable  tumors 
of  the  deeper  parts. 

The  appended  figures  represent  an  effort  to  show  graphi- 


132 


BENIGN  AND  MALIGN  CHARACTERISTICS. 


cally  some  of  the  major  differences  between  an  adenoma,  a  car- 
cinomaand  a  sarcoma. 

Fig.  26 


(     /y/=-.»?     St^^.l-^^^  ) 


Fig.  28 


PROPHYLAXIS  OF  MALIGNANCY.  123 

Treatment  of  Carcinoma.  The  treatment  of  mammary 
carcinoma  is  determined  absolutely  by  the  distribution  of  the 
lymphatic  drainage.  The  mortality  rate  from  the  radical  opera- 
tion would  be  very  much  lower  were  it  not  for  the  unfortunate 
fact  that  the  upper  inner  quadrant  drains  largely  into  the  an- 
terior mediastinal  glands  and  indirectly  into  the  liver.  Fortu- 
nately, however,  the  most  extensive  drainage  is  into  the  axil- 
lary and  supra-clavicular  groups.     (See  Fig.  25.) 

Thus  it  is  that  the  position  of  the  growth,  particularly  if 
it  be  a  small  one,  determines  the  extent  of  the  operative  inter- 
vention. If,  for  example,  the  outer  upper  quadrant  alone  is  in- 
volved, it  may  be  deemed  conservative  to  remove  no  more  than 
the  axillary  glands  with  pectoralis  major  and  minor.  If,  how- 
ever, as  is  too  frequently  the  case,  the  growth  when  operated 
upon  has  invaded  other  quadrants  of  the  breast,  the  supra-clavi- 
cular and  in  some  cases  even  the  anterior  mediastinal  glands 
are  taken  out.  The  first  calls  for  a  resection  of  the  clavicle ;  the 
second,  for  a  resection  of  a  portion  of  the  sternum.  The  immedi- 
ate mortality  of  the  operation  is  of  course  higher  if  the  medias- 
tinal glands  are  attacked,  but  the  chances  of  permanent  cure,  if 
the  patient  survive  the  operation,  are  enhanced. 

Prophylactic  after-Treatment  of  Malignancy. 

This  is  a  convenient  point  at  which  to  consider  the  after 
treatment  of  all  forms  of  malignant  disease  after  they  have- 
been  removed.  The  argument  in  general  is  this,  that  if  certain 
agents  about  to  be  described  are  curative,  as  they  have  posi- 
tively been  shown  to  be,  of  malignant  growths,  when  superfi- 
cially situated  may  these  agents  not  have  a  protective  power  in 
preventing  the  secondary  development  of  malignancy  after  the 
tumors  have  been  removed  by  the  knife?  It  is  accordingly  the 
custom  of  some  surgeons  to  treat  their  cases  according  to  the 
terms  of  this  argument.  Some  of  the  treatments  referred  to- 
are : 

(i)  The  X-Ray.  Both  the  curative  and  prophylactic  power 
of  this  agent  are  generally  recognized.  .  The  chief  danger  and 
difficulty  has  been  the  indiscriminate  use  of  the  rays  by  ignor- 
ant or  unscrupulous  operators.  Such  men  yield  to  the  tempta- 
tion to  advocate  radio-active  treatment  in  the  case  of  deep- 
growths,  where  the  knife  only  is  indicated. 


124  PROPHYLAXIS. 

(2)  Finsen's  Light.  This  was  originally  obtained  by  con- 
centrating the  sun's  rays  through  huge  water  glass  lenses,  the 
circulation  of  the  water  cooling  the  rays  sufficiently  to  prevent 
their  burning.  It  is  now  obtained  chiefly  from  electric  lights. 
Action  depends  on  the  unknown  power  of  the  violet  and  ultra- 
violet portions  of  the  light.  The  work  done  by  these  rays  is 
accomplished  by  vibrations  which  do  not  appear  to  us  as  color, 
because  of  their  being  situated  ultra  or  beyond  the  violet  side 
of  the  spectrum.  They  are  too  rapid  for  sight-perception.  The 
chief  function  of  the  Finsen  rays  probably  is  in  the  treatment 
•of  Lupus. 

(3)  Static  Spray.  This  is  simply  the  discharge  from  a 
powerful  static  machine  applied  to  the  part  from  a  metal  point. 
The  erythema  produced  is  similar  to  'that  of  the  X,  and  the 
Finsen  Rays,  but  the  curative  properties  are  more  limited. 

(4)  Radium.  This  remarkable  element  possesses  curative 
powers  similar  to  those  of  the  X  Ray.  They  are  stated  by 
Abbe  to  be  ten  times  less  potent.  It  has,  in  addition  to  its 
therapeutic  properties  the  remarkable  ability  to  retard  develop- 
mental processes.  Abbe  has  shown  that  seeds,  if  exposed  to 
radium  radiations,  are  retarded  in  their  growth  proportionately 
to  the  time  of  exposure,  and  he  has  further  demonstrated  that 
meal  worms,  which  ordinarily  complete  their  cycle  of  develop- 
ment in  about  three  months,  if  exposed  to  radium,  remain  meal 
worms ;  refusing  for  an  indefinite  period  to  manufacture  their 
■cocoons. 

(5)  Starvation.  This  treatment  has  been  elaborately 
worked  out  by  Dawbarn,  and  he  has  conclusively  shown  that 
in  certain  forms  of  sarcoma  it  is  of  distinct  value  and  possibly 
so  in  the  case  of  other  malignant  growths.  The  principle  is  to 
cut  off  as  much  nutrition  as  possible  without  causing  the 
healthy  parts  to  slough.  Its  most  favorite  site  for  employment 
is  after  the  removal  of  sarcomatous  growths  from  the  region  of 
the  antrum  or  lower  face.  The  technic  consists  not  in  ligation 
but  in  actual  excision  of  the  great  bulk  of  the  arterial  and  ven- 
ous supply. 

The  treatment  then  of  malignant  disease  as  exemplified  in 
the  breast,  consists  of  early  removal,  followed  by  prophylactic 
treatment.  This  may  be  by  prolonged  exposure  to  Radio-activ- 
ity or  by  Starvation. 


CHAPTER  XI. 
STOMACH  AND  GUT. 


^ranches  fy 


OTa,vchcs  to 
Ca.rcCtt. 


Fig.  29 
CELIAC  AXIS. 

This  drawing  represents  the  stomach  as  a  transparent  body  through 
which  can  be  seen  the  pancreas  and  its  arteries.  To  draw  the 
Celiac  Axis  draw  the  lines  1,  2  and  8  (see  small  cut  to  right  and 
below  the  main  one.)  Then  join  1  to  8  and  2  to  3  in  the  manner 
shown.  Subdivide  the  terminations  of  the  lines  1,  3  and  8  and 
compare  the  result  with  the  large  sketch. 


126  GROSS  PATHOLOGY  OF  ULCER. 

It  is  Utopian  to  look  for  the  last  days  of  proprietary  diges- 
tants,  but  it  is  conservative  to  say  that  in  future  there  will  be 
more  stomach  lesions  treated  by  the  knife  than  by  purgative 
pills  and  predigesting  powders. 

We  eat  well  but  not  wisely  hence  the  stomach  has  many 
minor  woes.  Aside  from  these,  the  most  interesting  and  most 
vitally  important,  because  of  its  relation  to  carcinoma,  is 

GASTRIC  ULCER. 

The  etiology  of  the  condition  is  unknown,  but  it  probably 
has  much  to  do  with  repeated  traumata  of  the  mucosa.  The 
pathology  presents  characteristic  phenomena.  The  ulcer  is  ty- 
pically, a  punched  out  area  in  the  mucous  membrane  which 
may  sometimes  be  seen  through  the  serosa  as  a  whitish  region. 
It  is  white,  partly  because  of  anemia — the  nutrient  vessel  which 
can  usually  be  found  leading  to  the  center  of  the  ulcerated  re- 
gion, is  very  often  thrombosed  or  plugged — partly  because  of 
the  formation  of  scar  tissue,  which  is  here  made  with  unusual 
rapidity. 

W.  J.  Mayo  states  that  probably  fifty  per  cent,  of  cases  of 
gastric  ulceration  are  complicated  by  a  similar  duodenal  lesion. 
Until  quite  recently  duodenal  ulcers  were  supposed  to  have  a 
rather  constant  relation  to  burns  and  other  skin  lesions.  The 
ulcer  bearing-  area  of  the  stomach  is  rather  strictly  (80  per 
cent.)  localized  on  the  posterior  gastric  surface,  near  the  py- 
lorus ;  the  ulcer  bearing  region  of  the  duodenum  is  limited  to 
the  first  portion  of  that  gut.  It  would  therefore  seem  that  there 
is  some  physiologic  or  anatomic  factor  which  renders  this  four 
or  five  inches  of  what  is  practically  a  funnel  particularly  prone 
to  ulceration.  This,  though  ignorance  of  its  true  cause,  must 
at  present  be  termed  spontaneous. 

There  are  other  regions  of  the  alimentary  canal  which  are 
prone  to  ulceration,  but  these  ulcers  are  of  a  distinctly  different 
type,  tubercular,  typhoid  and  the  like.  There  is  no  other  region 
in  the  entire  gut  so  liable  to  idiopathic  ulceration  as  this  short 
pyloric  funnel.  Before  attempting  to  give  any  differential 
tables,  it  should  be  stated  that  a  positive  diagnosis  in  most 
lesions  of  the  abdomen  is  possible  only  after  exploratory  in- 
cision and  often  not  even  then.     On  account  of  the  juxtaposi- 


DUODENAL  RELATIONS.  127 


■f^am     "Py/ort/s  +o 

9aHT.Vuuacn,.7  a-^t,^ 
CorriTnofy    ■9/7e  KXuQ'f- 


Fig.  30 
Relations  of  1st  part  of  Duodenum. 


Qui 


l/tnm   Cava 
Uym-f-mr. 


CoJoyt 


Fig.  B1 
Relations  of  2nd  part  of  Duodenum. 


128 


ULCER-BEARING  PYLORIC  FUNNEL. 
(Xhove.  'pa-ncrcaf. 


(^<^-7>»T,^„„e<i) 


Covered  '"  ■/'•««'*  *v 

^t^y   ^.ea.-/  of  ni^scn'^'ry. 


^^/. 


a.T»i/>*lr. 


Fig.  82 
Relations  of  4th  part  of  Duodenum. 

tion  of  the  gall  bladder  and  its  ducts  to  the  duodenum  and  the 
stomach,  lesions  of  these  parts  are  apt  to  be  confounded. 

Duodenal  Ulcer  because  of  these  studies  is  coming  into 
great  prominence  and  the  time  probably  is  not  distant,  when, 
instead  of  reference  being  made  to  gastric  or  to  duodenal  ulcer, 
separate  and  apart  from  each  other,  efforts  will  centre  on  the 
demonstration  of  ulceration  in  the  ulcer  bearing  pyloric  funnel 
already  referred  to.  Nevertheless,  it  is  still  stated  that  duode- 
nal ulcers  have  certain  distinguishing  characteristics.  They 
are  so  vague,  however,  that  Brewer  states  it  to  be  impossible 
to  differentiate  the  pyloric  ulcer.  No  attempt  will  therefore 
be  made  to  do  it. 

Duodenal  ulcers  are  said  to  occur  in  two  per  cent,  of  bad 
burns.  This  percentage  was  much  higher  in  the  pre-antiseptic 
days.  They  may  also  follow  frost  bite,  erysipelas,  pemphygus, 
septicemia  and  eczema.  Their  possible  exciting  etiology  may 
be  (i)  Septic  emboli;  (2)  Destruction  of  blood  cells;  (3)  Ab- 
sorption of  toxins  from  cellular  degeneration ;  (4)  Nerve  irri- 
tation. They  may  appear  from  four  to  six  days  after  the  burn 
or  injury. 


DIFFERENTIAL  BETWEEN 


129 


Carcinoma  of 
Pylorus. 


Ulcer  of  Pyloric 

Funnel. 


Gall  Stones  of 
Common  Duct. 


Chronic 
Cholecystitis. 


Absent  in  early 
stage. 


Onset  always 
slow.  Progress- 
ively worse. 
Cachexia. 


Gastric  ulcer  or 
primary  carci- 
noma elsewhere 


Over  forty. 


Male. 


History  of  Tumor. 
Rarely  present.        Absent. 

History  of  Disea.sk. 


Onset  more  rapid. 
Characterized  by 
exacerbations. 


Onset  abrupt. 
Acute  exacer- 
bations. 


Previous  Disease. 
Chlorosis.  Typhoid  fever. 

Age. 


Under  forty. 


Female. 


Mid-adult  life. 
Sex. 

Female. 
Occupation. 


Negative. 


Change  from  an 
active  out-door 
to   a    sedentary 

•  one,  as  seen  in 
the  case  of  emi- 
grant servant 
girls. 


Commonly  ascrib- 
ed to  indolence 
and  over-eating 
but  by  a  recent 
continental 
writer  thought 
to  be  due  to  the 
opposite. 


Pain. 


to  3  hours  after 
eating.  Charac- 
teristic. Grind- 
ing. Rarely  be- 
gins at  night. 


Chronic  dyspepsia 
Progressive 

weakness. 


Ch  a  r  ac  t eristic. 
Acute.  Relation 
to  eating,  direct 
and  immediate. 
Rarely  begins 
at  night. 


Remittent.  Se- 
vere. Shoulder. 
No  relation  to 
eating.  Typic- 
ally begins  at 
night. 


Disability. 


Intermittent  dys- 
pepsia. Acid 
eructations. 


Low  grade  chron- 
ic d  ysp  ep  sia, 
frequent. 


Frequent. 


Onset  slow. 
Chronic  course 
with  exacerba- 
tions. 


Chronic  duodenit- 
is. 


Mid-adult  life. 


Female. 


Negative. 


Intermittent.  Less 
severe.  Only 
with  exacerba- 
tions. Usually 
begins  at  night. 


Dyspepsia, 
mittent. 
ous". 


inter- 
"Bili- 


130 


DIFFERENTIAL  BETWEEN.— Continued. 


Carcinoma  of 
Pylorus. 


Ulcer  of  Pyloric 
Funnel. 


Gall  Stones  of 
.  Common  Duct. 


Chronic 
Cholecystitis, 


Bowels. 


Negative. 


Uncommon,  ex- 
cept in  exten- 
sive involve- 
ment produ- 
cing pressure  on 
the  duct. 


Normal. 


Occasional  "tarry  " 
movements. 


Constipation. 
May  be  "clay" 
movements. 


Jaundice. 


Absent. 


Absent. 


Negative. 


A  b  s  en  t ,  except 
under  similar 
conditions, 
which  are  rarer 
than  in  carcino- 
ma. 


A  very  character- 
istic symptom. 


Temperature. 


Variable. 


Characteristically 
intermit  tent. 
Chills  and 
sweats,  98  to  103 


NERVOUS  SYMPTOMS. 
Delirium. 


Absent. 


Absent. 


Negative. 


Not  infrequent. 


Paresthesiae. 


Constipated. 


Frequent     during 
exacerbations. 


Present  during  ex- 
acerbations. Ir- 
regular: 98-103. 


Occasionally  dur- 
ing exarcerba.' 
tions. 


Itching  of  skin.        Occasional  itching 


Urine. 


High-colored   and 
stains  linen. 


Same   during   ex- 
acerbations. 


Evidence    of    ca- 
chexia. 


GENERAL  PHYSICAL. 

Inspection. 


Pallor  and  pro- 
nouned  anemia. 


Yellow. 


May  be  yellow. 


LOCAL  PHYSICAL. 

Inspection. 

Possible  tumor,      l^'^^f^^     ""^    ^"Jno  tumor. 


Probable  tumor.. 


131 


DIFFERENTIAL  BETWEEN— Continued. 


Carcinoma  of 
Pylorus. 


Ulcer  of  Pyloric  .  Gall  Stones  of 
Funnel.  Common  Duct. 


Chronic 
Cholecystitis. 


Palpation. 


May  feel  tumor  onj 
deep  respiration  I Q 
Tenderness  nearP^™^- 
mid-line.  • 


No  tumor.  Ten- 
derness at  "Rob- 
son's"  point. 


BLOOD. 

Leucocytosis. 


About  60%,  8,000. 
About  20%,  10- 
000  to  12,000. 
About  20%,  20- 
000  to  40,000. 
(Cabot) 


Depends    on    de- 
gree of  cachexia 


About  20'/^.,  10,000 
to  12,000. 


Usually  absent. 


Hemoglobin. 

One-half  have  lessl 
than  50%  (Cab-  70  to  80% 

ot)  I 

URINE. 

Indican. 


Very  frequent.        Absent. 


Absent. 


Ffxes. 


Undigested     food 

particles. 


Evidences 
blood. 


of 


Absence  of  color- 
ing matter. 


Exploratory  Incision. 


Tumor  usually  at 
pylorus  or  on 
lesser  curvature 


Ulcer  50%  in  first 
part  of  duode- 
num remainder 
on  posterior  py- 
loro-gastric  wall 


Tumor. 


Stone  often  lodg- 
ed im  ampulla 
of  Vater. 


May  be  marked 
during  exacer- 
bation. 


70  to  80% 


Absent. 


Coloring  matter 
may  be  absent 
during  exacer- 
bation. 


Dilated  or  atro- 
phied diseased 
gall-bladder. 


As  in  the  case  of  the  breast,  probably  the  most  interesting 
as  well  as  the  most  vital,  question  in  the  surgery  of  the  stomach 
is  the  problem  which  bears  on  the  relation  of  a  carcinoma  to 
a  gastric  ulcer.  In  the  breast  it  is  frequently  a  benign  tumor, 
that  is  to  say,  a  growth  not  traumatic  in  origin,  which  under- 


132  SURGERY  OF  THE  STOMACH. 

goes  the  degenerative  malignant  change.  There  are,  however, 
many  examples  to  show^  that  the  chronic  irritation  arising  from 
mild,  low  grade  infection,  as  often  occurs  in  frequently  fissured 
nipples  and  similar  apparently  insignificant  lesions  have  a  very 
important  bearing  upon  malignant  degeneration.  In  the 
stomach,  benign  tumors  are  rare,  the  source  of  malignancy  tak- 
ing its  origin  almost  entirely  in  the  bed  of  old  inflammatory 
lesions  (ulcers).  Chronic  irritation  then  plays  ^  most  import- 
ant part  in  the  stomach  and  this  is  further  exemplified  by  the 
very  fact  that  carcinoma  of  the  stomach  is  much  more  frequent 
in  men  than  in  women.  Men  eat  too  much  and  eat  too  indig'es- 
table  substances.  There  is  probably  some  connection  between 
these  two  facts. 

Pain,  dyspepsia,  acid  eructations,  loss  of  weight,  vomiting ; 
these  are  some  of  the  symptoms  which,  singly  or  in  combina- 
tion, bring  the  patient  to  the  surgeon's  observation.  Every  one 
of  these  sufferers  has  been  subjected  to  all  conceivable  and  to 
many  inconceivable  forms  of  treatment.  They  have  been 
bathed  in  boiling  and  sprayed  in  ice  cold  water.  They  have, 
for  hours  at  a  time,  knelt  with  their  buttocks  on  high  and  their 
heads  on  low.  They  have  suffered  great  iron  balls  to  be  rolled 
and  tumbled  over  their  tender  belly  walls.  They  have  con- 
sumed thousands  of  dollars  worth  of  drugs.  They  are  at  last 
coming  to  their  own  !  , 

The  symptoms  above  referred  to  arise  directly  from  the 
inflammation  of  nerve  terminations  as  in  the  case  of  ulcer,  or 
indirectly,  as  in  the  case  of  carcinoma  and  other  diseases  which 
produce  pyloric  obstruction,  through  a  stretching  of  the  parts 
and  a  necessity  arising  for  them  to  do  work  for  which  they 
were  not  built. 

Surgery  applies  to  the  stomach  the  simple  common  sense 
methods  that  she  utilizes  elsewhere.  She  puts  inflated  parts 
at  rest  and  establishes  drainage. 

The  surgery  of  the  stomach  is  easy  to  understand  and 
there  can  be  no  possible  misconception  about  it  if  these  two 
simple  facts  are  remembered. 

What,  for  example,  is  the  surgical  treatment  of  ulcer  of 
the  stomach?  Put  the  part  at  rest.  Since  the  ulcer  is  usually 
located  near  the  pylorus,  if  this  funnel  be  put  out  of  use,  the 


TWINE-TRIANGULAR  STITCH. 


rss. 


•ulcer  will  heal.  Consequently  one  of  the  most  frequently  em- 
ployed technics  for  the  treatment  of  ulcer  (Robson,  Moynihan 
and  others)  is  Gastro-enterostomy. 


Fig.  33 

Gastro-enterostomy  made  by  the  twine-triangular  stitch. 
(Columbia  Surgical  Laboratory) 

This  deservedly  popular  operation  serves  the  s-econd  in- 
dication, viz. — that  of  establishing  drainage  just  as  admirably 
as  it  does  the  first.  For  this  reason,  it  is  employed  in  the  treat- 
ment (palliative  in  the  case  of  carcinoma,  as  are  many  surgical 
operations)  of  Pyloric  stenosis.  All  the  great  and  little  evils 
from  which  a  case  of  pyloric  carcinoma  suffers  are  done  away 
with  as  though  by  magic  through  the  execution  of  gastro-en- 
terostomy. The  technic  is  simple.  The  jejunum  and  the 
stomach  may  be  brought  into  communication  by  ligature  and 
section  :  by  Murphy  Button  ;  by  the  the  Tv/ine-triangular  stitch 
(see  Report  from  Columbia  Surgical  Laboratory,  1904.) 


134 


REST  AND  DRAINAGE. 


Other  methods  are  used  for  the  relief  of  these  lesions  of 
the  stomach,  but  they  must  always  be  based  on  the  simple 
proposition  of  rest  and  drainage.  Finney's  pyloroplasty  is  ac- 
knowledged to  be  the  best  of  these.     See  Brewer's  text  book. 


Fig.   34 
POSTERIOR  RELATIONS  OF  STOMACH. 

The  Greater  Curvature  has  been  lifted  upward  and  to  the  left. 
This  accounts  for  distorted  (diagrammatic)  shape  of  the  stom- 
ach.    Note  that  head  of  pancreas  is  not  in  relation. 


Gastrostomy. — Occasionally  because  of  impassible  stric- 
ture of  the  esophagus,  a  permanent  opening  has  to  be  made  in 
the  stomach  through  which  the  patient  may  be  fed.    A  similar 


SURGERY  OF  TYPHOID  ULCERS.  135 

Opening  occasionally  has  to  be  made  in  the  colon  through 
which  the  patient  may  in  case  of  permanent  obstruction  or  des- 
truction of  the  rectum  evacuate  his  bowels.  There  is  no  truer 
example  than  that  found  in  a  study  of  Gastrostomy  and  Colos- 
tomy, of  the  axiom  that  to  succeed,  an  operation  must  imitate 
nature  as  closely  as  possible.  She  has  passed  through  the  ab- 
dominal wall  a  tube  which  for  all  practical  purposes  is  similar 
to  the  rubber  tube  used  in  gastrostomy.  It  is  the  spermatic 
cord.  It  traverses  the  abdominal  wall  by  an  intermuscular 
course.  The  length  of  the  canal  is  constant  and  the  relation  of 
the  muscles  to  it  is  always  the  same.  The  most  effectual  means 
of  establishing  a  permanent  opening  into  the  stomach  or  the 
colon  is  based  upon  the  principle  that  it  should  be  made  as 
nearly  like  the  inguinal  canal  as  possible.  That  is  all  there  is  to 
these  so  called  valve  or  telescoping  operations  ;  they  simply  im- 
itate nature. 

Surgical  treatment  of  typhoid  ulcers.  As  about  8,000  peo- 
ple a  year  die  in  the  United  States  alone  of  perforation  or 
hemorrhage  from  typhoid  fever,  it  is 'obviously  an  important 
matter  to  reach  a  means  of  treating  this  vital  condition  surgi- 
cally. 

In  a  very  high  percentage  of  cases  the  lesion  takes  place 
within  the  last  24  inches  of  the  ilium.  The  symptoms  of  per- 
foration classically  are  pain,  sudden  and  sharp  attended  by  col- 
lapse, but  unfortunately  there  are  too  few  cases  that  follow  the 
classical  picture.  It  has  been  suggested  as  a  palliative  method 
that  some  coagulable  jelly-like  material  should  be  injected  into 
the  gut  somewhat  as  engineers  sometimes  put  oatmeal  into  a 
leaking  boiler.  Increased  assurance  in  the  opening  of  the  abdo- 
men under  local  anesthesia  will  undoubtedly  do  a  great  deal  to 
help  this  rather  discouraging  situation.  . 

APPENDICITIS. 

There  is  not  an  unmixed  joy  in  being  a  new  woman.  She 
has  appendicitis  just  about  as  often  as  her  brother.  Formerly 
he  had  it  four  times  to  her  once,  but  now  that  she  bicycles  cen- 
turies, plays  golf  and  basket  ball,  she  has  in  more  than  one 
sense   become   his   equal.     This   seems   to   be    rather   convin- 


136  TOXICITY  RAISED  BY  PRESSURE. 

cing  that  violent  exercise  has  a  good  deal  to  do  with  the  et- 
iology of  appendicitis. 

It  has  been  noticed  that  prolonged  and  violent  bicycle  rid- 
ing, for  instance,  has  in  an  unusual  number  of  cases  been  fol- 
lowed by  an  acute  attack.  This  suggests  that  overaction  of  the 
psoas  in  the  case  of  an  appendix  which  droops  down  into  the 
pelvis  by  bringing  it  thousands  of  times  in  harsh  contact  with 
the  pelvic  brim  gives  the  disease  its  first  start. 

The  suggestion  that  women  are  usually  so  less  liable  to 
appendicitis  than  men  because  of  the  greater  blood  supply  to 
the  organ  in  the  female  has  probably  been  shown  to  be  erron- 
eous by  the  facts  already  cited.  Vascularity  it  is  now  believed 
has  little  or  nothing  to  do  with  the  etiology. 

Stricture  of  the  organ  is  usually  present.  It  is  easy  to  con- 
ceive that  stricture  here  will  act  just  as  it  does  elsewhere,  viz. — 
for  example  in  the  urethra.  Some  variation  in  temperature, 
some  unusual  germ  activity,  or  some  unknown  conditions  may 
be  s\ipposed  to  start  the  elements  of  a  simple  exudative  inflam- 
mation. It  is  known  that  the  bacillus  coli  is  practically  ubiqui- 
tous. It  has  been  found  in  the  gut  of  birds  killed  far  out  at 
sea.  It  is  therefore  in  most  cases  a  resident  of  the  appendix 
throughout  the  length  of  its  lumen.  What  happens  after  the 
inflammation  begins?  The  stricture  swells  and  distal  to  it  there 
is  shut  in  by  the  obliteration  of  the  lumen,  a  little  lake-like  area 
which,  if  not  already  full  of  fluid,  rapidly  fills  after  its  closure. 
The  fluid  is  rich  in  food  stuffs  and  it  is  at  98.6,  the  temperature 
most  favorable  for  the  development  of  pathogenic  germs.  It  is 
inevitable  that  the  colon  bacilli  propagate.  Among  the  prod- 
ucts of  their  metabolism  are  gases.  These  together  with  other 
metabolic  outputs  are  created  more  rapidly  than  the  dilated 
and  engorged  vessels  of  the  part  can  carry  away.  Pressure  in 
the  little  lake  results.  The  effect  of  grovnng  germs  under  pres- 
sure is  a  very  constant  one.  Germs  producing  substances  poi- 
sonous to  man,  when  put  under  pressure  are  more  dangerous 
than  otherwise.  Germs  which,  like  the  colon  bacillus,  are  harm- 
less to  us  under  the  usual  conditions  of  pressure,  become  viru- 
lently poisonous  when  this  is  augmented.  Thus  is  explained 
the  great  virulence  and  the  remarkable  local  destructive  power 
of  the  fluids  contained  within  these  appendicular  sacs. 


137 


DIFFERENTIAL  BETWEEN- 


Appendicitis. 


Right  Sided  Sal- 
pingitis. 


Right  Ruptured 
Ectopic. 


Acute 
Cholangitis. 


History  of  Tumok. 


Very  frequent.        Frequent. 


Absent. 


Onset  slow,  belly- 
ache. 


Constipation  and 
previous  at- 
tacks. 


Male,  3  to  1. 


History  of  Disease. 

Onset  fulminat- 
ing ;  very  severe 


Onset  slow;  pelvic 
cramps. 


pelvic  cramps. 
Previous  Disease. 


Absent. 


Onset  acute ;  belly- 
ache. 


Gonorrhea. 


Often     previous 
pregnancies. 


Female. 


Sex. 


Female. 


Social  State. 


Typhoid. 


More   frequent   in 
female. 


Single. 


Begins  at  navel 
and  radiates  to 
McBurney's 
point. 


Very  frequent. 


Prostitutes. 


Married. 


Pain. 


Begins  in  pelvis. 
May  be  referred 
down  right  leg. 


Most  severe  of  all. 
Localized  in  pel- 
vis or  referred. 


Negative. 


Severe.  Often  re-, 
f erred  to  Rob- 
son's  point. 


Infrequent 


Absent. 


101  to  103. 


Full,    120   usually 
regular. 


Absent. 


101  to  103. 


Vomiting. 

Very  rare. 
Jaundice. 

Absent. 
Temperature. 


).5  to  99. 


Pulse. 


Same. 


Weak,  140  to  160, 
irregular  defi- 
cient, short  and 
compressible. 


Frequent. 


Frequent. 


101  to  103. 


Full  120  regular. 


^138 


DIFFERENTIAL  BETWEEN— Continued. 


Appendicitis. 


Right  Sided  Sal- 
pingitis. 


Right  Ruptured 
Ectopic. 


Acute 
Cholangitis. 


GENERAL  PHYSICAL. 

Inspection. 


Flushed,  anxious 
asthenic,  febrile 
look. 


"Often  tumor. 


'Board  like"  ab- 
domen. Vaginal 
negative.  Press- 
ure pain  at  Mc- 
Burney's  point. 


Very  limited  area 
of  flatness. 


,000  to  11,000 
means  (A)  mild 
case.  (B)  very 
severe  case.  (C) 
Abscess  walled 
off.  Increasing 
1  e  u  c  o  c  y  t  osis 
may  be  only 
evidence  of  dis- 
ease. (Cabot) 
20,000  to  80,000 
not  uncommon. 


0.9 


Same  but  often  to 
a  less  degree. 


Pale,  sweaty,  pros- 
trated, asthenic 
look. 


LOCAL  PHYSICAL. 

Inspection. 


Possibly  tumor. 


Absent. 


Palpation. 


Rigid  right  side 
but  less  marked 
than  in  appendi- 
citis. Vaginal 
tumor.  Pain  in 
lower  right  a  b- 
d  o  m  i  n  a  1  seg- 
ment. 


Diff^use  moderate 
rigidity.  Vagi- 
nal; boggy,  se- 
vere pressure 
pain.  Abdomen 
filled  with  fluid. 


Often  negative. 


Percussion. 

Flatness  in  flanks 
disappears  on 
turning  patient 
on  side. 


Same    as     salpin- 
gitis. 


Absent. 


Moderate  rigidity  > 
tenderness  i  n 
upper  right  ab- 
dominal seg- 
ment. 


Limited     flatness 
tip  of  ninth  rib. 


BLOOD. 

Leucocyte  Count. 


Same  as  appendi- 
citis, but  less 
marked. 


16,000  to  18,000. 


20,000  to  30,000. 


0.9 


Color  Index. 


0.5  to  0.6 


-Abscess  found  at  Abscess    of   right 
caput  coli.  tube. 


Exploratory  Incision. 

Free  blood  in 
periteneal  cav- 
ity. 


0.9 


Dilated  gall  blad- 
der. 


OCHSNER'S  TREATMENT.  139 

The  blood  has  come  to  be  a  most  efficient  aid  in  diagnosing 
■appendicitis  and  in  differentiating  it  from  certain  other  condi- 
tions. It  is  readily  seen  that  the  appendix,  the  tube  and  the 
gall  bladder  are  organs,  which  although  occupying  different 
positions  in  the  abdominal  cavity,  have  nevertheless  almost 
identical  anatomical  structure.  It  is  probable  that  no  disease 
develops  either  in  the  tube  or  in  the  gall  bladder  except  by 
stricture  formation.  As  in  the  case  of  the  appendix  drainage 
is  interfered  w^ith  and  the  distal  parts  of  the  organ  become  shut 
off  so  as  to  form  practically  a  culture  tube  for  germs.  These 
will  not  make  trouble  so  long  as  there  is  no  pressure  and  in 
the  presence  of  unrestricted  circulation.  In  the  face  of  such 
resemblances  it  is  natural  that  the  blood  should  not  give  much 
differential  information  between  these  three  conditions.  It 
should  be  remembered  that  it  is  not  so  much  a  question  of  the 
amount  of  pus,  but  the  degree  of  tension  under  which  it  is  pent 
up  which  determines  the  amount  of  leucocytosis.  A  gum  boil 
under  pressure  will  often  give  a  count  of  20,000. 

Whereas  the  presence  of  leucocytosis  is,  in  many  cases 
very  variable,  there  is  a  list  of  diseases  which  are  definitely  and 
constantly  characterized  by  its  absence.  They  are  as  follows: 
(Cabot)  (i)  Typhoid,  (2)  Malaria,  (3)  Grip,  (4)  Measles,  (5) 
Rotheln,  (6)  Mumps,  (7)  Cystitis,  (8)  Tuberculosis— all  forms, 
including  miliary  and  tuberclous  peritonitis. 

In  typhoid  and  miliary  tuberculosis  the  leucocytes  are 
often  diminished. 

Leucopenia  is  a  diminution  of  the  number  of  white  cells. 
It  is  present  not  alone  in  tuberculosis  and  typhoid,  but  to  a  less 
degree  during  stages  of  most  of  those  infectious  diseases  which 
are  not  characterized  by  leucocytosis. 

The  treatment  of  appendicitis  is  the  most  difficult  of  the 
usual  problems  presented  to  the  surgeon.  There  are  two  dis- 
tinct schools,  the  one  advocates  operating  when  the  diagnosis 
is  made;  the  other,  except  in  chosen  cases,  advises  subjecting 
the  patient  to  a  special  form  of  treatment  prior  to  operation. 

This  is  known  as  Ochsner's  Treatment.  It  consists  in  giv- 
ing the  patient  absolutely  nothing  by  mouth,  not  even  water; 
in  administering  enough  morphine  to  relieve  pain ;  in  never 
giving  any  form  of  purgation  whatsoever.     The  object  is  to 


140  INVAGINATION  OF  APPENDIX. 

apply  the  surgical  principle  of  putting  the  inflamed  part  at  rest 
and  of  allowing  nature  to  "wall  off"  the  abscess.  It  is  said  that 
so  successful  has  this  treatment  been  in  some  cases  that  ab- 
scess formation  has  even  been  prevented  by  it.  Its  use  is  justi- 
fied, however,  as  distinctly  insisted  upon  by  Ochsner,  only 
after  a  thorough  understanding  of  its  contra-indications. 

Probably  the  most  popular  method  of  removing  the  ap- 
pendix is  by  that  first  suggested  by  Dawbarn.  He  has  always 
thought  that  the  hole  left  after  removal  of  the  organ  is  exactly 
similar  to  that  created  by  a  bullet  and  should  in  all  common 
sense  be  subjected  to  similar  treatment.  It  is  therefore  more 
surgical  to  throw  a  purse  string  suture  around  the  stump  prior 
to  cutting  off  the  organ  and  to  invert  it  into  the  gut  by  trac- 
tion than  to  use  pure  carbolic  or  the  actual  cautery  to  destroy 
the  mucous  membrane  that  the  parts  may  heal. 

THE  COLON. 

The  colon  has  recently  become  the  subject  of  special  sur- 
gical interest,  because  of  the  necessity  of  treating  some  of  the 
chronic  diarrheas  and  dysenteries  (particularly  the  amebic 
form)  by  surgical  intervention.  These  forms  of  colon  inflam- 
mation were  first  brought  prominently  into  notice  by  soldiers 
who  came  home  from  Cuba  and  the  Philippines.  No  form  of 
internal  medication  served  to  relieve  the  condition  and  many 
of  them  died.  Thirty  to  forty  movements  a  day  were  not  un- 
common, and  that,  in  spite  of  the  most  active  medicinal  treat- 
ment. In  these  desperate  cases  it  was  suggested  to  do  a  right 
sided  colostomy  with  adequate  spur-formation. 

The  advantage  of  the  spur  is  that  it  turns  every  particle 
of  fecal  material  on  to  the  surface  and  thus  allows  the  distal 
portion  of  the  gut  to  be  sterilized  and  kept  clean.  Its  disadvan- 
tage is  that,  unless  established  by  some  procedure  as  recom- 
mended by  Bodine,  in  which  case  it  can  be  broken  through  with 
a  Paquelin  cautery,  it  necessitates  a  secondary  and  often  a 
very  severe  operation.  The  spur  then  is  indicated  in  all  con- 
ditions where  radical  treatment  has  to  be  applied  distally  to  it. 
It  is  not  indicated  in  those  cases  where  an  opening  is  made,  as 
for  instance  in  strangulated  hernia,  simply  for  the  relief  of  in- 


"MARSUPIALIZATION"  141 

tra-enteric   pressure.     The   importance   of   the    inter-muscular 
operation  in  this  connection  has  already  been  discussed. 

Weir,  when  the  pertinence  of  the  surgical  treatment  of  the 
colon  became  manifest,  suggested  with  custornary  ingenious- 
ness,  that  instead  of  bringing  the  colon  to  the  surface  and  thus 
doing  an  ordinary  colostomy,  the  appendix  should  be  utilized 
to  connect  the  colon  with  the  outer  world.  Twelve  to  twenty- 
four  hours  after  the  appendix  had  been  made  fast  in  the  ab- 
dominal wall,  its  tip  was  to  be  nipped  ofif  and  disinfecting  irri- 
gation fluids  squirted  through  it  into  the  colon  and  rectum. 
This  technic  will  not  shunt  the  gut  contents  to  the  surface  as 
in  the  case  of  the  spur  operation,  but  for  amebic  dysentery  it 
serves  the  purpose  equally  well.  When  the  enteritis  is  cured 
presto !  a  hot  iron  shall  be  thrust  into  the  lumen  of  the  appen- 
dix, thus  closing  the  colostomy  and  incidentally  doing  away 
with  the  appendix.  This  method  has  been  widely  used  and  has 
been  called  Weir's  Marsupialization.  (The  marsupial  has  a 
pouch  in  which  its  young  are  carried.  The  term  and  principle 
are  sometimes  used  in  surgery.) 

THE  RECTUM. 

Fissure^  Fistula  and  Hemorrhoids  are  the  three  most  com- 
mon lesions  of  the  rectum.  They  cause  untold  suffering  and 
unless  relieved  are  the  very  type  of  chronic  injury  which  is  lia- 
ble to  malignant  degeneration.  It  is  therefore  of  very  great 
importance,  not  only  for  the  relief  of  immediate  pain  and  dis- 
comfort which  they  cause,  but  for  the  more  far  reaching  dan- 
ger to  which  they  subject  the  patient,  that  they  should  be  in- 
telligently treated.  One  of  the  most  favorite  differentials  is 
between  these  three  ills.  It  will  be  noted  that  the  most  im- 
portant differential  point  is  the  time  of  occurrence  and  the 
character  of  the  pain.  It  is  usually  possible  to  make  a  differ- 
ential on  the  history  alone  and  this  is  often  convenient. 


142 


DIFFERENTIAL  BETWEEN 


Fissure  in  Ano.     Fistula  in  Ano. 


Hemorrhoids. 


Early 
Malignancy. 


Absent. 


Onset  sudden. 


Negative. 


Absent. 


History  of  Tumor. 


Present. 


Disease. 
Onset  slow.  Onset  slow. 

Previous  Operation. 


Not  infreqtaent. 


Injections. 


Pain. 


Intermittent.! 
Sudden,     knife- 
like.    Last  only  Discomfort  only. 
10  ^seconds  after 
bowels  move. 


Remittent. 
Heavy,  drag- 
ging. Severe  for 
two  hours  after 
bowels  move. 


Disability. 


Afraid  to  have  a  Cannot    hold    gas 
movement.  and  fluid. 


Weak    from    loss 
of  blood. 


Present. 


Onset  very  slow. 


May  follow   hem- 
orrhoid removal; 


Not  characteristic 


Weak     from     be- 
ginning cachexia. 


INTESTINAL  OBSTRUCTION. 

This  is  probably  the  most  frequently  asked  of  all  hospital 
questions.  It  is  therefore  worth  while  to  condense  it  into  a& 
short  a  space  as  possible.    It  is 

Acute:  Chronic. 

Causes  Acute. 

Intussusception  (acute).  Bands.  Volvulus.  Foreign  bod- 
ies, gall  stones  and  enteroliths.  Internal  hernia 
(Meckels  diverticulum  and  abdominal  fossae.) 

Causes  Chronic. 

Impacted  feces,  strictures  (benign  and  malignant).. 
Intussusception  (chronic.) 


INTESTINAL  OBSTRUCTION.  143: 

Pathology  Acute. 

Above  obstruction  equals  gas. 
Below  obstruction  equals  empty. 

At'  obstruction  equals  ulceration,  perforation,  periton-. 
itis. 

Pathology  of  Chronic. 

In  and  above  equals  hypertrophy. 
Below  equals  empty  and  atrophy. 
At  obstruction  equals  same  as  acute. 

Symptoms  of  Acute. 

Same  as  acute  strangulated  hernia.  ■    • 

Pain,  sudden  and  diffuse. 

Collapse. 

Tenderness,  little  or  none. 

^T  •,•  (  High — early,  billious. 
Vomitmg  i  T  i  ^      i       i 

'='  i  Low — late,  fecal. 

Constipation  absolute  (obstipation.) 

Tympanites. 

Hiccough. 

Peristalsis  (if  walls  thin). 

Increasing  dysuresia. 

Pulse  rapid  and  feeble. 

Temperature  and  tenderness  from  peritonitis  only. 

Great  prostration  and  emaciation  if  last  long  enough.. 

DIFFERENTIAL. 
Does  Obstuction  Exist? 

History  of  Hernia  in  unusual  places. 

History  of  feces  or  foreign  body. 

Save  and  inspect  urine,  feces  and  vomit. 

Examine  for  concretion,  bile,  bloody  and  mucous  dis-- 

charge. 
Examine  for  external  hernia;  uneven  abdominal  disten-. 

tion. 

Rectal  examination  for  invagination,  feces  or  stricture. 
Palpate   and   percuss   abdomen   for   tumor,   tenderness,, 

tympanites.     (Do  not  put  hand  sound  or  measured'. 

enema  in   rectum). 


il44  INTESTINAL  OBSTRUCTION. 

Differentiate   from   Gastro-enteritis. 
Early  state  Meningitis. 
Biliary  and  renal  colic. 
Peritonitis. 
Appendicitis. 
Pyosalpinx. 
Gastric  ulcer. 
Acute  Cholecystitis. 

Where  is  Obstruction? 
SMALL  GUT. 
Obstruction  High — Symptoms. 
Violent  onset. 
Early  collapse. 

Early  and  persistent  vomiting,  bilious  rarely  fecal. 
Tympanites  absent  or  limited  to  epigastrium. 
More  or  less  dysuresia. 

LARGE  GUT. 
Obstruction  Low — Symptoms. 
Onset  slow  and  mild. 
Increase  in  violence  of  symptoms. 
Collapse  late  (except  in  volvulus). 
Tympanites   first   in   colon,   then 
Vomiting. 
Abdomen  more  bulging  on  side  than  center. 

Obstruction  in  Jejunum  or  Ilium — Symptoms. 

Eliminate   duodenum,  colon  and  rectum. 

Course  moderately  rapid. 

Vomiting  fairly  early. 

Tympanites  later. 

Abdomen  more  distended  at  center  than  at  side. 

What  is  Obstruction? 
Acute  Invagination — Symptoms. 
Child. 

Elongate  tumor  on  left  side  felt  via  anus. 
Tenesmus   and   bloody  discharge. 
Local  pain. 
Sudden  onset. 


INTESTINAL  OBSTRUCTION.  145 

Bands — Symptoms. 

History  of  previous  peritonitis. 
Tuberculosis   elsewhere. 
Local  pain. 

Volvulus — Symptoms. 

Old  males.  •  ' ' 

Localized  tympanites. 

"  tumor. 

"  pain. 

Usually  left  iliac  fossa  in  sigmoid.    Note.    Worst  of  all. 

Foreign  Bodies — Symptoms. 
History  false  teeth. 
Biliary  colic. 
Constipation. 
Palpation. 

Internal  Hernia — Symptoms. 

Local  pain  and  tenderness  over  the  abdominal  fossae. 

Chronic  Obstruction — Symptoms. 

Includes  symptoms. of  impacted  feces. 
Tumefaction  in  colon. 
Rectal  examination  for  feces. 
Old  people. 
Young  girls. 

Stricture— Symptoms, 

History  of  dysentery.  ■' 

Symptoms  of  visceral  malignancy. 
Old  people. 

Chronic  Invagination — Symptoms. 
History  stricture  or  tumor. 
Tumefied  colon,  not  compressible. 
Mucous  and  bloody  stools. 
Tenesmus. 


146  INTESTINAL  OBSTUCTION. 

Treatment  of  all  Forms. 
Lavage. 
Opii. 

No  cathartics. 
Enemata. 
Spoon  out  recti! m. 
No  tubage  of  colon. 
No  puncture  of  intestine. 
Uniform  and  continuous  abdominal  pressure. 
Laparotomy. 
Enterotomy. 
Enterectomy. 

Enterrorhaphy   and   anastomosis. 
Colostomy. 


CHAPTER  XII. 


LIVER,  SPLEEN  AND  PANCREAS. 

The  surgery  of  the  liver  centers  on  the  relief  of  disorders 
of  its  secretory  passages.  So  called  gall  stone  colic  is  probably 
(Brewer)  not  due  to  gall  stones  at  all,  but  to  spasmodic  con- 
traction of  the  inflamed  ducts  pressing  on  the  nerves. 

The  Gall  Bladder  is  directly  connected  with  the  surface  of 
the  body  and  so  is  the  liver.  They  are  therefore,  in  common 
with  other  organs  situated  upon  the  surface  of  the  body,  sub- 
ject, first,  to  superficial  invasions  by  germs  and  animal  paras- 
ites, and  second  to  the  particular  form  of  malignant  degenera- 
tion to  which  the  surface  is  liable,  viz. — Carcinoma.  Bacterio- 
logically  speaking,  the  inner  and  outer  body  surfaces  are  dirty. 
As  the  liver  and  pancreas  are  the  most  deeply  situated  of  these 
superficial  organs,  it  is  appropriate  here  to  show  a  diagram 
which  proves  this  somewhat  surprising  hypothesis. 

It  is  simply  a  question  of  remembering 
that  there  are  two  surfaces,  an  outer  and  an 
inner,  and  these  organs  together  with  the 
parotid  gland,  the  hepatic  gland  and  certain 
others,  are  located  on  the  inner  surface. 

The  Liver  is  occasionally  the  seat  of  ab- 
scess. It  has  to  be  differentiated  from  sub- 
phrenic abscess,  which  is  a  collection  of  pus 
immediately  beneath  the  diaphram,  due  usu- 
ally to  gastric  ulcer;  from  costo-phrenic  ab- 
scess, which  is  a  collection  of  pus  in  the 
costo-phrenic  sinus,  a  sketch  of  which  is 
shown  in  Chapter  X,  and  from  empyema. 
Note  that  an  important  factor  in  this  differ- 
ential is  the  effect  of  respiration  upon  the 
discharge   of  the  pus  after  exploratory  incision. 


Figure  of  barrel  show- 
ing inner  and  outer 
surface. 


148 


DIFFERENTIAL  BETWEEN 


Liver  Abscess. 


SuK- Phrenic  Ab- 
scess. 


Costo-Phrenic 

Abscess. 


Empyema. 


Previous  Diskask. 


Duct,    cystic   or 
duodenal   infec- 


Amebae. 


Pus  may  flow 
faster  during  in- 
spiration (dia- 
phragm goes 
down.) 


Gastro  -  duodenal 
ulceration. 


Thoracic 

tions. 


infec-  Pneumonia  or 
Pleurisy. 


Exploratory  Puncture. 

I  P  n  e  u  m  o  coccus : 


Pyogenic     organ- 
isms. 


T.  B. ;  Strepto- 
or  S  taph  y  1  o- 
coccus. 


Same. 


Incision. 


Same. 


Pus  may  flow 
faster  during 
expiration  (dia- 
phragm goes  up) 


Same. 


The  liver,  on  account  of  being  on  the  surface,  is  occasion- 
ally, as  already  said,  the  subject  of  parasitic  invasion.  Liver 
abscess  may  be  grossly  divided  according  to  the  three  zones 
in  which  it  is  most  prone  to  occur. 

Frigid  Zone  or  Echinococcus  Cyst.  The  Echinococcus  as  it 
occurs  in  man  is  the  asexual  form  of  the  tenia  echinococcus  of 
the  dog.     It  is  a  moderately  small  tape  worm. 

The  Laplanders  live  in  such  intimate  relations  with  their 
dogs  that  their  food  habitually  becomes  contaminated  with  the 
animal's  feces.  Consequently  in  Lapland  and  throughout  the  re- 
gion where  dogs  are  largely  used  for  transportation  purposes, 
man  is  very  frequently  the  subject  of  echinococcus  infection. 

The  cyst  formed  by  this  parasite  is  characterized  by  multilo- 
cular  formation,  having  daughter  and  grand-daughter  cysts. 

Torrid  Zone  or  Ameba  Cyst.  In  the  Torrid  Zone,  the 
ameba  of  dysentery  abounds.  Not  infrequently  it  finds  its  way 
from  the  gut  into  the  liver.  The  result  is  the  amebic  or  dysen- 
teric abscess  characterized  by  being  single  and  by  a  rather 
strict  localization  to  the  southern  climes.     (See  Chapter  XV^I.) 

Temperate  Zone  or  Pyemic  Cyst.  The  Temperate  Zone  is 
not  exempt  from  its  peculiar  abscess.    We  do  not  live  in  close 


CLASSIFICATION  OF  CYSTS.  149 

communion  with  our  dogs,  or  suffer  from  amebic  invasion. 
Amebae  are  frail  and  require  the  bad  hygiene  and  torrid  heat 
of  the  tropics.  We  have  with  us,  however,  as  steady  compan- 
ions, many  pyogenic  bacteria.  Any  one  of  these  may  make 
the  characteristic  Temperate  Zone  or  pyemic  abscess. 

These  abscesses  or  cysts  of  the  liver  suggest  a  classification 
of  cysts.     Cysts  may  be  conveniently  divided  into 

(i)   Retention. 

(2)  Distention. 

(3)  Tubular. 

(4)  Glandular. 

(5)  Parasitic. 

(6)  Dermoid. 

The  only  way  to  get  hold  of  this  classification  is  to  apply  it. 
It  will  be  noted  that  a  cyst  is  often  to  be  described  by  using 
a  combination  of  these  terms.  For  example,  it  is  either  reten- 
tion-tubular or  retention-glandular,  as  the  case  may  be.  Take 
a  Glactiferous  Cyst  for  instance.  That  is  caused  by  pent  up 
milk  in  the  milk  ducts.  Now  the  mammary  gland  secretes  a 
fluid  which  is  intended  to  come  to  the  surface.  Cysts  of  it  are 
therefore  retention  cysts.  This  is  because  what  was  intended 
to  come  out,  is  retained.  The  Glactiferous  Cyst  therefore,  be- 
cause the  milk  is  retained  in  tubes,  is  a  retention-tubular  cyst. 
Distention  cysts,  on  the  other  hand,  occur  in  regions  where 
the  secretion  is  not  intended  to  come  to  the  surface,  as  for  ex- 
ample in  the  case  of  a  bursa.  Cystic  change  in  this  is  called 
bursitis.  It  is  a  distention  cyst.  These  occur  also  in  the  duct- 
less glands,  as  in  the  ovary  or  thyroid.  They  may  therefore, 
as  in  these  two  latter  cases,  be  called  distention-glandular  cysts. 
A  distention-tubular  cyst  obviously  cannot  well  exist.  The 
echinococcus  cyst  is  an  excellent  example  of  the  parasitic  cyst, 
which  is  here  meant  to  mean  an  animal  parasite. 

Some  of  the  more  common  animal  parasites  of  man  in 
addition  to  the  echinococcus  are  described  in  Chapter  XVI. 

SPLEEN. 

(J)n  account  of  the  vascularity  of  this  organ,  practically  all 
that  can  be  done  to  it  is  puncture  or  removal.  Puncture  is  con- 
fined to  obtaining  from  it  specimens  of  central  blood  in  which 


150 


RELATIONS  OF  PANCREAS. 


certain  forms  of  parasites,  unwilling  to  circulate  in  the  peri- 
pheral blood,  are  resident. 

Excision  or  Splenectomy,  while  a  formidable  operation, 
is  the  only  possible  chance  for  patients  suffering  from  splenic 
pseudo-leukemia.  Spleiiectomy  is  also  the  only  possible  means 
of  treating  idiopathic  splenic  enlargement. 

Banti's  disease,  a  condition  of  splenic  enlargement,  asso- 
ciated with  hepatic  cirrhosis,  is  another  condition  for  which 
splenectomy  is  undoubtedly  indicated.  Other  conditions  which 
may  call  for  removal  are :  rupture,  wandering  spleen,  cysts, 
tumors  and  malarial  hypertrophy. 

PANCREAS. 


Tv-ferio-T     tTl'-ScnferK:    Vein, 
•Superior    Wcsevft-ri-z       l/C/ri, 


Fig.  36 

RELATIONS  OF  PANCREAS. 

(Seen  from  the  front) 


J{J.    o^. 


PANCREATITIS.  151 

Much  of  the  recent  surgery  of  the  abdomen  centers  upon 
the  pancreas.  The  diseases  of  this  organ  have  a  very  intimate 
relation  to  those  of  the  liver  and  bile  duct.  Acute  pancreatitis, 
both  hemorrhagic,  suppurative  and  gangrenous,  is  one  of  the 

least  understood  abdominal  lesions.  It  may  arise  from  ordi- 
nary germ  infection,  just  as  in  the  case  of  other  organs,  but 
there  is  a  rather  constant  relation  of  biliary  duct  disease  to  it, 
which  makes  it  seem  probable  that  in  many  cases,  at  least,  tin's 
is  a  powerful  predisposing,  if  not  actually  an  indispensable 
cause. 

Acute  hemorrhagic  pancreatitis  is  characterized  by  the 
usual  evidences  of  intra-abdominal  inflammation  ;  rigidity,  ten- 
derness, distention  and  very  severe  pain.  On  account  of  the 
depth  of  the  organ  a  definite  tumor  rarely  appears.  The  con- 
dition cannot  be  diagnosed  except  on  exploratory  incision.  In 
its  later  stages  it  is  differentiated  by  exclusion — because  of  the 
appearance  of  their  characteristic  symptoms — from  perforated 
duodeno-pyloric  ulcer  ;  from  appendicitis  ;  from  acute  intestinal 
obstruction  ;  from  peritonitis  ;  from  acute  cholecystitis ;  from 
pyonephrosis.  The  difficulty,  however,  of  waiting  for  differen- 
tial points  to  arise  is  that  unless  relieved  in  its  early  stages, 
acute  hemorrhagic  pancreatitis  usually  kills  in  a  very  few 
hours.  The  recognition  then  of  acute  hemorrhagic  pancreatitis 
depends  only  upon  exploratory  incision.  The  moment  the  ab- 
domen is  opened,  white  patches  are  seen  throughout  the  omen- 
tum and  in  the  mesentery.  They  vary  from  the  size  of  a  pin's 
head  to  large  irregular  masses.  They  are  the  so-called  areas  of 
fat  necrosis.  The  origin  of  this  fat  necrosis  is  not  3^et  under- 
stood but  it  is  supposed  by  some  to  be  due  to  the  liberation  in 
the  abdominal  civity  of  the  fat  splitting  ferment  of  the  pancreas. 
The  objection,  however,  to  this  theory  is  that  fat  necrosis  has 
been  seen  in  these  cases  occuring  in  fatty  areas  where  it  seems 
improbable  that  the  ferment  could  have  reached  it.  The  sub- 
ject is  therefore  subjudice.  The  gland  when  exposed  is  found 
to  be  spachelous  and  as  the  shock  of  removal  would  certainly 
kill  the  patient,  all  that  can  be  done  is  to  see  that  adequate 
drainage  is  established. 

Chronic  pancreatitis  or  the  development  in  the  organ  of 
dry  productive  inflammation,  is  an  interesting  and  not  infre- 


152 


AMPULLA  OF  VATER. 


quent  disorder.  Even  more  than  the  acute  form  it  has  a  rela- 
tion to  interference  of  the  gall  duct  circulation.  Opie  has 
shown  that  in  many  cases  there  exists  in  the  ampulla  of  Vater 
a  gall  stone  which,  too  large  to  pass  out  through  the  papilla, 
is  yet  large  enough  to  net  within  the  ampulla  as  a  ball  valve. 

It  is  clear  that  when  the  ampulla  is  blocked,  the  bile  must 
pass  directly  up  through  the  pancreatic  duct  into  the  pancreas. 
The  patency  of  the  accessory  ducts  (Santorini)  of  the  pan- 
creas are  of  obvious  importance  in  safeguarding  the  individual 
from  chronic  pancreatitis  arising  in  this  way.  If  present  they 
maintain  adequate  pancreatic  drainage. 

DIFFERENTIAL  BETWEEN 


Chronic  Pancrea- 
titis. 


Chronic  Gastro- 
Duodenal  Ul- 
ceration. 


Chronic  Chole- 
cystitis. 


Liver    Carcinoma 


History  of  Tumor. 


Rare. 


Onset  characteriz- 
ed by  rapid  loss 
of  weight. 


Possible. 


Frequent. 


Disease. 


Onset    follows  Onset  often    cha 


symptoms  of 
acute  ulcer. 


racterized  by  at- 
tacks of  colic. 


Unusual. 


Onset  slow  and 
marked  by  in- 
creasing  ca- 
chexia. 


LOCAL  PHYSICAL. 

Palpation. 


May  be  feeling  of 
deep   resistance 


Negative. 


Tumor  near  pylo- 
rus. 


Tumor  tip  of  9th 
rib. 


LABORATORY. 

Chb;mical  of  Stomach  Contents. 


Liver  below  carti- 
lages and  may 
be  nodular. 


Excess  of  HCl  and 
blood. 


Usually  excess  of! 
Carbon    Com-  Same, 
pound  Acids.      | 


"Clay"  stools  due 
to  exeess  of  fat. 


Tumor  of  head 
of  pan  cr eas 
grossly  indistin- 
guishable from 
Carcinoma. 


Feces. 


'Tar"  stools. 


'Clay'  stools  due  tol 
absence  of  color-  Normal, 
ing  matter.  | 


Exploratory  Incision. 


m  e       1  1  Dilated  gall  blad-i 

Tumor  of  pylorus     derusullly  filled  Usually   multiple 
of  similar  type.      ^^.^j^  ^^^^>^__        I  -  ^ 


CHAPTER  XIII. 
GENITO-URINARY. 

Custom  has  more  or  less  extensively  welded  these  widely 
differing  branches.  There  is  less  reason  for  their  union  in  the 
light  of  to-day  than  there  was  in  the  past.  They  are  further- 
more badly  confused  with  the  term  "venereal." 

THE  KIDNEYS. 

These  organs  are  reached  by  one  of  three  general  incisions. 
Probably,  the  most  common  extends  along  the  outer  border  of 
the  erector-spinae,  from  a  point  half  an  inch  distal  to  the  last 
rib  (to  avoid  wounding  the  diaphragm,  see  Fig.  of  this  muscle 
under  hernia)  to  a  point  at  the  level  of  the  iliac  crest.  The 
incision  may  then  turn  (Konig)  and  sweep  transversly  around 
the  trunk  in  the  direction  of  the  umbilicus  as  far  as  may  be 
necessary.  This  incision  affords  the  best  view  obtainable  of 
the  kidney  and  is  indicated  for  the  major  operations  as  well  as 
(the  first  part  of  it)  for  minor. 

The  second  incision  starts  at  the  same  point  and  runs 
parallel  to  the  twelfth  rib  one-half  inch  from  it  (diaphragm) 
for  a  distance  of  eight  or  ten  centimeters.*  This  incision  is  a 
useful  one  for  minor  work  and  has  the  advantage  of  lying  in 
the  direction  of  the  spinal  nerves  which  are  therefore  much  less 
likely  to  be  injured  than  if  its  course  lay  across  them. 

The  kidney  is  also  reached  by  a  transperitoneal  route.  A 
ten  centimeter  opening  is  made  at  the  outer  border  of  the 
rectus,  having  its  lower  limit  about  on  a  line  with  the  umbil- 
icus. When  the  small  guts  are  cleared  away  a  right  angle  tri- 
angle is  seen,  bounded  above  by  the  transverse  colon,  exter- 
nally by  the  ascending  or  descending  colon,  according  to  the 
side  operated,  and  internally  by  a  retracted  mass  of  small  guts. 
On  deep  retraction,  the  floor  of  this  triangle  will  be  seen  to  be 
white.     This  is  the  perinephritic  fat.     The  retro-peritoneum  is 

*  The  two  systems  are  purposely  confused. 


154 


RENAL  RELATIONS. 


'^/Cf/,*       /tT/e/^ 


''y 


UEveL  of 
~     'JEZDona.)  — 


LBvSt-a-f 


"iTT'"' LarnBAK  .       ^"^'^    ^^"=^' 


cy 


Fig.   37 — Anterior  Relations  of  Kidnevs. 


tik^ 


Fig.  38 — Posterior  relations  of  Kidneys. 


fit  (fhi-      /^'cfni  y- 


DIFFERENTIAL. 


155. 


incised  in  the  line  of  the  original  skin  cut  and  the  kidney  cap- 
sule is  brought  into  view.  This  incision  has  certain  advantages 
claimed  for  it,  but  it  is  objectionable  because  of  the  danger  of 
soiling  the  peritoneum  if  pus  be  found.  It,  furthermore  pro- 
duces greater  shock  than  the  posterior  incisions. 

Nephropexy.  This  is  a  sewing  of  the  kidney  to  the  poster- 
ior abdominal  wall.     It  is  for  the  relief  of  floating  kidney. 

This  disorder  is  characterized  by  a  prolapse  of  the  organ 
distal  to  the  umbilical  plane  of  the  body.  A  great  many  kid- 
neys are  so  relaxed  in  their  attachment,  due  presumably  to  con- 
genital over-development  of  the  fatty  capsule,  that  they  wander 
at  will  as  far  down,  at  times,  as  the  pelvis.  This  does  not 
signify  anything  except  in  the  presence  of  symptoms  and  unless 
these  exist  to  a  constant  and  incapacitating  degree,  the  case 
should  not  be  operated  upon.  The  symptoms  referred  to  are 
often  of  a  vague  and  indeterminate  character,  making  a  posi- 
tive diagnosis  of  the  condition,  except  for  the  ability  to  feel  the 
organ,  a  difficult  one.  It  has  to  be  differentiated  from  recurring 
appendicitis,  nephralgia  and  nephrolithiasis.  It  may  well  be 
said  that  in  order  to  do  this,  all  that  is  necessary  to  do  is  to 
palpate  the  patient's  side.  This  is  true,  but  there  are  numerous 
people  walking  around  to-day  supposed  to  have  gastritis  and 
innumerable  other  diseases,  who  really  have  a  floating  kidney, 
and  on  the  contrary,  many  who  actually  have  such  a  lesion  as. 
recurrent  appendicitis,  are  prowling  around  with  kidney  pads 
on  their  back.  This  shows  the  value  of  following  some  care- 
fully planned  scheme  for  differentiation. 

DIFFERENTIAL  BETWEEN 


Prolapsed  Kidney 


Recurrent  Ap- 
pendicitis. 


Gastritis. 


Nephrolithiasis. 


History  of' Tumor. 


Often  present. 


Intermittent,  oft- 
en severe,  re- 
ferred. 


Generally  dyspep- 
sia or  dvsuresia. 


Possibly  present. 


Absent. 


Pain 
Intermittent,      al- 
ways severe,  lo- 
calized. 

DiSAKILITY 

Interval     period 
grows  shcjrter. 


Absent. 


„       -...11  I  Intermittent,  very 

Remitten,    less        ^^^^^^    referred' 
severe,  localized  |      ^^  genitals. 


Chronic  dyspepsia 


Complete     during 
attack. 


156 


DIFFERENTIAL  BETWEEN.— Continued. 


Prolapsed  Kidney 


Recurrent  Ap- 
pendictis. 


Gastritis. 


Nephrolithiasis. 


Vomiting. 


Very  frequent. 


Frequent. 


Typical    in   the 
morning. 


LOCAL  PHYSICAL. 

Palpation. 


Bi-manual,  fee  llRight  sided  rigid- 
organ  below  na-i  ity, — may  be  tu- 
vel.  Little  or  no'  mor.  Pressure 
tenderness.  j     pain. 


Diffuse  pressure 
pain  only.  No 
tumor. 


LABORATORY. 

Motor  Power  of  Stomach. 


K.  I.    appears    in 
urine  late. 


Blood  freezes  at 
normal  tempera- 
ture. 


-Negative. 


Normal. 


Normal. 


Negative. 


Very  late. 

Cryoscopy. 

Normal. 

X  Ray. 

Negative. 


Rare.       Nausea 
from  pain. 


No  tumor.  May 
be  localized 
pressure  pain 
along  course  of 
ureter. 


Normal. 


Apt  to  be  raised. 


Positive. 


CRYOSCOPY. 

Among  numerous  other  aids  to  diagnosis  which  have  re- 
cently been  developed  in  the  study  of  renal  disease,  one  of  the 
most  interesting  is  cryoscopy.  In  the  normal  individual,  the 
blood  freezes  at  a  very  constant  temperature. 

This  point  varies  so  little,  in  the  absence  of  renal  involve- 
ment, that  it  may,  for  clinical  purposes  be  considered  con- 
stant. The  ftmction  of  the  kidney  is  to  separate  from  the  blood 
certain  solid  products  of  metabolism.  These  are  removed  at 
the  same  rate  at  which  they  are  manufactured  and  thus  the 
^saline  elements  of  the  blood,  which  are  the  factors  determin- 
ing its  freezing  point,  are  kept  in  constant  relation  to  the 
plasma.     If,  however,  the  function  of  the  kidney  is  impaired, 


SEGREGATION  METHODS.  157 

this  relation  changes.  One  of  the  most  convenient  methods  of 
determining  the  degree  of  change  which  has  taken  place  is  to 
test  the  freezing  point  of  the  blood.  Of  course  if  the  kidneys  are 
diseased  and  there  are  more  salts  in  the  blood  than  there  nor- 
mally should  be,  the  freezing  point  will  be  lower,  because,  as 
is  well  known,  salt  water  requires  a  lower  temperature  to  freeze 
it  than  fresh. 

One  would  expect  the  converse  to  be  true,  viz. — that  the 
diminished  amount  of  solids  in  the  urine  should  show  in  the 
same  constant  manner  and  by  the  same  cryoscopic  method  as 
in  the  case  of  the  blood.  In  the  opinion  of  Bevan,  however, 
who  with  his  assistant  has  probably  done  more  of  this  work 
than  anybody  else,  the  cryoscopic  testing  of  the  urine  has  no 
value  whatsoever.  He  looks  upon  this  test  as  applied  to  the 
blood,  however,  as  having  very  far  reaching  and  important  sig- 
nificance. His  limits  he  states  to  be  between  0.51  in  a  case  of" 
anemia  and  0.78  in  a  case  of  aneuria. 

The  X-Ray  has  been  used  very  widely  in  the  diagnosis  of 
nephro-lithiasis.  The  technic  has  been  so  far  perfected  that  it 
is  now  stated  (Bevan,  Leonard,  Blake  and  others)  to  be  pos- 
sible to  establish  a  positive  or  a  negative  diagnosis  of  stone  in 
the  kidney,  pelvis  or  ureter  more  certainly  by  this  means  than 
by  any  other.  It  has  largely  superseded  Kelly's  waxed  tipped 
bougies,  which  were  ureteral  probes  dipped  in  wax  and  then 
passed  without  touching  anything,  directly  into  the  ureter.  The 
distance  to  which  they  could  be  shoved  up  determined  the 
position  of  the  impacted  stone  and  a  microscopic  finding  of, 
scratches  on  the  wax  proved  that  it  had  come  in  contact  with 
the  stone. 

Ureteral  Catheterization  has  not  taken  such  a  prominent 
position  as  its  early  exploiters  believed  it  would.  This  is  prob- 
ably because  of  two  reasons.  First,  the  great  difificulty  in 
catheterizing  the  male,  second  and  all-important  the  fear  of 
carrying  infection  up  from  the  bladder.  It  is  a  means,  however,, 
of  obtaining  urine  from  one  kidney. 

Urinary  Segregation  is  a  method  which,  while  probably 
more  objectiona]:»le  to  the  patient,  is  fraught  with  less  danger  to 
him. 

Harris'  Segregator  is  an  instrument  for  obtaining  the  urine 


158  ARE  THERE  TWO  KIDNEYS? 

of  the  two  kidneys  separately.  It  is  an  ingenious  device  by 
which  a  tent-like  structure  is  inserted  into  and  opened  out  in 
the  rectum.  The  apex  of  the  tent  is  directly  under  the  trigone, 
which  it  lifts  up.  The  ureteral  openings  then  discharge  into 
two  little  lakes,  one  on  either  side  of  this  ridge  in  the  floor  of 
the  bladder.  Two  fine  separate  tubes  are  carried  by  the  in- 
strument in  such  manner  that  the  ends  dip  into  the  center  of 
these  ponds  of  urine.  Separate  bulbs  pump  these  ponds  dry, 
the  urine  being  poured  into  separate  bottles.  Up  to  date  this 
is  the  most  satisfactory  means  of  obtaining  separate  urine  from 
the  two  kidneys.  Moynihan  reports  that  a  new  French  in- 
strument which  unfolds  a  diaphragm  in  the  median  antero- 
posterior plane  of  the  bladder  is  reliable. 

The  importance  of  positively  separating  the  urine  cannot 
well  be  overestimated.  In  the  first  place,  it  is  probably  the 
most  practical  method  of  determining  that  more  than  one  kid- 
ney exists.  Before  removing  a  kidney  for  any  reason  whatso- 
-ever,  the  point  must  always  be  definitely  settled  that  it  is  not 
the  sole  and  solitary  organ  possessed  by  the  patient.  The  ac- 
cident of  removing  the  kidney  has  happened  to  a  large  number 
of  able  operators.  Formerly  there  existed  good  excuse  on  the 
ground  that  there  was  no  way  of  assuring  one's  self  except  by 
making  a  counter-incision.  This,  the  chance — one  in  a  great 
many  thousand — did  not  seem  to  justify.  It  is  most  interesting 
from  a  pathological  standpoint  that,  contrary  to  what  one 
would  expect,  these  patients  who  have  suffered  removal  of  their 
sole  kidney  and  therefore  are  destitute  of  any  renal  excretion 
whatsoever,  live  usually  from  a  week  to  ten  days! 

Renal  Sepsis.  Infection  of  the  kidney  and  its  pelvis  may 
occur  in  one  of  two  ways.  A  frequent  source  of  germ  invasion 
is  from  below.  This  is  sometimes  known  under  the  old  term 
of  "surgical  kidney."  The  infection  passes  upward  from  the 
l^ladder  or  ureter  and  is  distributed  among  the  tubular  ter- 
minations. The  other  method  is  by  deposition  of  germs  in  or 
about  the  glomerular  tufts.  They  are  carried  here  by  the  blood. 
This  is  therefore  a  pyemic  process. 

Clinically  these  two  methods  of  infection  are  indistinguish- 
able for  their  manifestations  are  the  same.  Historically  they 
may  differ.  On  section  of  the  kidney,  however,  if  too  much  de- 
generative process  has  not  taken  place,  they  can  readily  be  dif- 


DECORTICATION  VS.  CAPSULE  SECTION.  159 

ferentiated  by  the  presence  of  round  cell  infiltration  and  per- 
haps of  germs  in  the  regions  already  referred  to.  Whatever 
the  source  of  the  infection,  the  treatment  is  free  incision  and 
drainage. 

More  interest  has  recently  centered  in  the  results  of  treat- 
ing chronic  parenchymatous  nephritis  surgically  than  in  the 
more  fully  understood  cases  of  acute  renal  suppuration.  With- 
in the  past  year  a  large  number  of  patients  suffering  from 
chronic  parenchymatous  degeneration  of  the  kidneys  have  been 
subjected  to  the  so-called  Decortication  Operation.  This  tech- 
nic  in  itself  is  simple  enough,  consisting  as  it  does  in  executing 
the  first  part  of  the  technic  usually  employed  for  nephropexy, 
viz. — a  longitudinal  central  splitting  of  the  inner  capsule. 

The  effects  of  this  operation  in  a  certain  number  of  cases 
have  unquestionably  been,  to  say  the  least,  remarkable.  Dr. 
A,  H.  Ferguson  showed  such  a  case  at  the  recent  meeting  of 
the  American  Surgical  Association.  The  high  standing  of  this 
operator  and  the  unquestioned  integrity  of  his  pathological  ex- 
aminations, which  were  made  by  the  ablest  experts  and  upon 
which  the  pre-operative  diagnosis  was  based,  renders  it  im- 
possible to  deny  that  there  is  a  place  for  the  surgical  treatment 
of  chronic  parenchymatous  nephritis. 

It  has  been  claimed  that  the  good  accruing  to  the  patient 
arises  from  a  development  of  a  new  and  a  large  blood  supply 
to  the  organ.  This,  however,  seems  to  have  been  an  erroneous 
supposition  for  Emerson,  as  a  result  of  extensive  experimental 
observations  made  at  the  Columbia  Physiological  Laboratory, 
has  been  able  definitely  to  prove  that,  in  animals  at  least,  renal 
decortication  is  not  succeeded  by  the  development  of  an  ad- 
ventitious blood  supply  to  the  kidney.  It  has  been  noticed 
that  as  much  good  may  result  from  a  simple  section  of  the 
capsule,  with  or  without  an  accompanying  nephrotomy,  as  has 
been  observed  to  arise  from  a  thorough  decortication.  In  the 
absence  of  proof  that  increased  blood  supply  arises  after  this 
operation  in  man  ;  in  the  presence  of  positive  demonstration 
that  such  blood  supply  does  not  arise  in  animals,  and  on  ac- 
count of  the  fact  that  improvement  is  noted  after  a  variety  of 
operations  in  which  the  capsule  is  not  torn  off,  it  is  probable 
that  improvement  results  from  an  increased  nerve  stimulation 
rather  than  from  an  increased  blood  supply. 


160  SIGNIFICANCE  OF  BLOODY  URINE. 

The  ureters  occasionally  have  to  be  sectioned  and  re-united. 
This  operation  is  called  Uretero-ureterostomy.  Various  de- 
vices have  been  employed,  among  others  a  small  button  and 
a  diminutive  hammer.  The  button,  in  a  measure  resembles 
Murphy's  intestinal  button  and  the  hammer  serves  the  pur- 
pose of  juxtaposing  the  openings  while  suture  of  the  serous 
coat  is  in  progress.  The  union  of  this  tube  at  any  point  is 
easy,  so  that  throughout  its  length  it  enters  more  or 
less  widely  into  operative  technics.  The  treatment  of  the  ter- 
minal extremity  of  the  tube,  however,  is  a  very  different  con- 
sideration.    It  will  be  discussed  under  the  bladder. 

Robert  F.  Weir  used  to  say  that  blood  in  the  urine  meant 
in  a  very  large  proportion  of  cases  one  of  three  things.  Stone, 
Tuberculosis  or  Malignancy.  This  affords  an  admirable  illus- 
tration of  the  easy  applicability  and  the  accuracy  of  the  Sub- 
Scheme  for  giving  "Causes  of."  Hematuria  is  necessarily  not 
the  only  symptom  of  these  three  important  diseases,  but  Weir 
ingrafted  that  teaching  on  thousands  of  students  to  the  lasting 
good  of  the  public.  * 

THE  BLADDER. 

The  importance  of  this  reservoir  centers  largely  upon  its 
close  relation  to  other  pelvic  organs.  In  the  female  it  is  very 
apt  to  be  involved  secondarily  and  by  contiguous  infection  pro- 
cesses in  malignant  diseases  of  the  uterus.  It  is  thus  often 
necessary  to  resect  the  bladder  very  widely.  It  possesses  a 
remarkable  power  of  regeneration,  excellent  bladders  having 
been  created  from  a  dilatation  of  an  incredibly  small  portion 
of  mucous  membrane  left  behind  and  sewed  into  a  bag  at  time 
of  operation.  This  is  an  illustration  that  nature  produces  or- 
gans as  they  are  needed,  but  it  is  rare  indeed  that  she  is  able 
to  do  so  in  the  adult  human  being. 

Another  important  surgical  consideration  is  the  point  of 
entry  of  the  ureters.  Just  as  in  the  case  of  the  inguinal  canal 
and  the  duodenal  opening  of  the  duct  of  Wirsung,  so  here  na- 
ture has  made  use  of  the  inter-muscular  course.  For  from  two 
to  three  centimeters  the  ureter  passes  between  the  coats  of 
the  bladder  before  it  pierces  the  mucous  membrane.  It  can 
readily  be  seen  that  malignant;  tubercular  disease  or  injury 

*    An   important    differential    is   between    Nepliro-litliiasis,    Nephro- 
tuberculosis,  Nephro-malignancy  and  Nephralgia. 


IMPORTANCE  OF  URETERO-VESICAL  VALVES.  161 

might  make  necessary  the  removal  of  so  much  of  the  ureter 
that  the  ends  could  not  be  juxtaposed.  The  problem  then 
arises  what  to  do.  Even  in  view  of  the  very  extensive  work 
which  has  been  done  in  an  effort  to  answer  this  question  more 
satisfactorily  than  it  was  formerly  answered,  it  is  safer  for  the 
patient  that  the  entire  kidney  should  be  removed  rather  than 
that  any  attempt  be  made  to  leave  it  in.  This  necessitates 
caring  for  the  secretion  by  grafting  the  ureter  either  to  the 
surface  of  the  body  or  into  the  sigmoid. 

Madyl  was  the  first  to  suggest  the  desirability  of  preserv- 
ing the  uretero-vesical  valves.  He  advocates  cutting  out  a 
square  of  the  bladder  wall  of  sufficient  size  to  more  than  in- 
clude these  valves,  and  a  transplantation  of  this  segment  di- 
rectly into  the  sigmoid  at  such  a  position  that  a  convenient 
uretero-ureterostomy  can  be  made  between  the  proximal  and 
distal  ureteral  ends.  Some  cases  operated  upon  by  this  technic 
have  been  surprisingly  successful.  It  is  astonishing  howtolerant 
the  sigmoid  will  soon  become  of  urine,  and  the  qviantity  which 
it  will  hold  is  so  great  that  under  favorable  conditions,  the  in- 
dividual need  not  void  it  more  frequently  than  is  habitual. 
This  operation,  it  will  be  noted,  converts  the  patient  into  a 
bird  in  that  the  urine  and  the  feces  are  both  disposed  of 
through  a  common  opening  or  cloaca  (great  sewer). 

Unfortunately  even  with  Madyl's  technic,  the  uretero-ves- 
ical valve  is  usually  so  impaired  that  infection  from  the  sig- 
moid soon  passes  it,  ascends  to  the  kidney  and  kills  the  patient. 
This  is  why  it  is  probably  more  conservative  surgery  in  such 
cases  to  do  a  primary  nephrectomy.  A  third  important  rela- 
tion to  the  bladder  which  has  a  definite  bearing  upon  the  sur- 
gery of  the  organ  is  that  of  the  prostate.  This  gland  if  re- 
moved through  the  supra-pubic  region  can  be  reached  only 
after  anterior  and  posterior  section  of  the  bladder  wall.  The 
type  of  prostatic  treatment  instituted  in  a  given  case,  there- 
fore, has  an  important  bearing  on  the  bladder.  As  will  be 
explained,  however,  in  the  chapter  on  the  prostate,  this  rela- 
tion is  coming  to  have  less  importance  every  day. 

Stones  occasionally  form  in  the  bladder.  A  great  majority 
of  them  grow  after  the  manner  of  a  snow  ball,  by  rolling  round 
and   round   in   the  bladder.     There  has  to  be  a  beginning  or 


162  TESTICULAR  DIFFERENTIALS. 

center  for  the  concretionary  mass ;  this  may  arise  from 
bodies  introduced  from  without  or  may  come  down  in  the 
form  of  small  agminations  of  crystals  from  the  kidney. 

Bladder  stones  (Brewer)  may  be  composed  of 

Uric   Acid;   smooth,   round,   dark  brown. 

Ammonium  Urate ;  lighter  in  color. 

Calcium  Oxalate ;  very  hard,  dark  brown  or  black,  nodular 
rough  surface. 

Phosphatic;  white  and  friable. 

Composite  Stones. 

Cystine       j 

Xanthine    ' 

Positive  diagnosis  of  stone  can  be  made  only,  either  by 
touching  it  with  a  metal  sound;  by  seeing  it  through  the  cysto- 
scope,  or  by  the  X-Ray. 

Blood  in  the  urine,  if  not  from  the  kidneys,  frequently 
comes  from  the  bladder.  The  most  common  cause  of  a  bloody 
discharge  from  this  organ  is  the  so-called  papillomatous  tumor. 
It  is  a  benign,  pedunculated,  highly  vascular  growth,  not  un- 
common in  young  people  and  always  to  be  thought  of  in  con- 
nection with  hematuria.  The  important  dififerential  point  be- 
tween this  condition  and  the  three  renal  causes  of  hematuria 
already  cited  is  the  —  presence  or  absence  of  vesical  irritability. 

THE   TESTICLES. 

Syphilis  and  tuberculosis  attack  these  organs  with  about 
equal  frequency.  The  diseases,  therefore  occasionally  have  to 
be  differentiated  from  each  other  as  well  as  from  the  more 
common  gonorrheal  infection.  Practically  the  testicle  cannot 
be  invaded  without  a  certain  amount  of  sympathetic  involve- 
ment of  the  epididymis.  This  is  fortunate,  since  without  the 
epididymis  as  a  guide,  a  clinical  differential  would  be  difficult 
to  make.  In  syphilitic  involvement  the  enlargement  is  almost 
always  at  the  globus  major.  In  tuberculous  invasion  the  en- 
largement is  in  the  globus  minor.  The  syphilitic  lesion  there- 
fore is  proximal  to  the  tuberculous.  The  gonorrheal  lesion 
also  usually  occurs  in  the  globus  minor,  differential  between 
this  disease  and  tuberculosis  being  based  upon  history  rather 
than  physical  examination. 


GROSS  PATHOLOGY  OF  PROSTATE.  163 

For  those  who  liave  been  sterilized  by  gonorrheal  infection 
of  the  vas  deferens  and  epididimis  it  will  be  comforting  to 
know  that  the  occluded  vas  has  recently  been  cut  proximal  to 
the  stricture  and  grafted  into  the  testicle  with  good  functional 
result, 

THE  PROSTATE. 

If,  as  Osier  says,  pneumonia  is  the  friend  of  old  age, 
chronic  prostatitis  is  its  bitterest  enemy.  A  very  well-known 
authority  on  this  subject  recently  stated  that  the  mortality 
from  catheter  life  should  be  placed  at  one  hundred  per  cent. 
Even  ardent  advocates  of  this  ancient  method  of  treating  the 
chronically  enlarged,  obstructing  prostate,  are  obliged  to  con- 
fess that  the  average  duration  of  life  under  the  catheter  is  net 
more  than  four  or  five  years. 

Freyer  (Lancet,  July  23d,  04)  states  that  the  prostate  is  in 
reality  composed  of  twin  organs  of  apparently  purely  sexual 
function.  This  twin  formation  is  seen  typically  among  some 
of  the  lower  vertebrates,  and  it  is  always  found  in  man  during 
the  first  four  months  of  life. 

it  is  evident  from  this  that  instead  of  calling  the  organ  the 
"prostate"  we  should  speak  of  the  prostates. 

There  are  two  moot  points  in  the  gross  pathology  of  these 
organs.  First,  as  to  the  so-called  "capsule."  Second,  as  to  the 
so-called  middle  lobe. 

Freyer  likens  the  two  organs  to  an  orange.  He  states  that 
the  analogy  would  be  complete  if  an  orange  segmented  into 
two  halves,  instead  of  into  many  small  pieces.  Imagining  such 
an  orange,  the  true  prostatic  capsule  is  analagous  to  the  delicate 
coat  which  envelopes  fhe  edible  portion  of  the  orange.  The 
"false"  capsule,  or  what  is  usttally  known  as  the  "capsule," 
corresponds  to  the  thick  rind  of  the  fruit. 

The  "middle  lobe"  does  not  exist  as  a  thir-d  division  of  a 
single  organ,  as  it  is  usually  described,  but  is  in  reality  simply 
the  over-folded,  upward-protruding  margins  of  the  two  lateral 
lobes  or  two  prostates,  as  they  evidently  should  now  be  con- 
sidered. 

More  revolutionary  work  has  been  done  on  the  subject  of 
prostatectomy  in  the  last  year  than  in  any  other  department 


164  PERINEAL  PROSTATECTOMY. 

of  surgery.  There  are  consequently  almost  no  text  books 
thoroughly  up  to  date  on  this  new  surgery.  The  contributions 
of  Young,  Sims,  Goodfellow  and  Tinker  presented  in 
1904,  to  the  Surgical  Section  of  the  American  Medical  Asso- 
ciation ofifer  the  matter  in  such  a  new  light  and  withal  in  such 
an  authoritative  light,  that  it  may  be  looked  upon  as  almost 
entirely  remade. 

Together^  they  reported  over  one  hundred  and  fifty  cases 
of  perineal  prostatectomy  in  which  there  had  occurred  the 
astonishingly  small  mortality  rate  of  less  than  three  per  cent! 
This  is  an  utterly  different  teaching  from  that  of  recent  text 
books,  which  quote  mortality  rates  of  from  fifteen  to  twenty- 
five  per  cent. 

Tinker's  contribution  to  the  subject  is  of  the  utmost  impor- 
tance. He  has  demonstrated  that  prostatectomy  may  actually 
henceforth  be  relegated  to  the  domain  of  minor  surgery!  Old 
men,  victims  of  advanced  arterial  sclerosis,  often  do  not  take 
kindly  to  a  general  anesthetic.  Tinker  injects  the  long  puden- 
dal and  the  internal  pudic  nerve,  where  they  course  around  the 
tuberosity  of  the  ischium,  as  shown  in  the  figure,  with  massive 
infiltration  anesthesia  after  the  method  of  Matas.  His  patients 
suffer  no  pain  whatsoever ;  they  complain  simply  of  being, 
wearied  by  their  cramped  position  on  the  table. 

One  of  the  most  remarkable  facts  in  connection  with  this 
subject  of  perineal  prostatectomy  is  that  the  patients  are  al- 
lowed to  get  up  and  walk  about  their  rooms  in  from  twelve  to 
thirty-six  hours.  They  suffer  no  discomfort  in  so  doing  and 
prevent  the  possible  development  of  hypostatic  pneumonia. 

The  consensus  of  surgical  opinion,  as  shown  at  this  meet- 
ing, is  that  the  perineal  operation  is  the  technic  of  choice ; 
that  the  gland  should  be  removed  under  local  anesthesia,  and 
that  the  operation  should  be  done  as  early  in  the  course  of  the 
disease  as  possible. 

Bottini's  Operation.  This  technic  has  been  given  rather 
wide  attention  here  recently  on  account  of  the  work  of 
Young  and  others.  Two  years  ago  Young  utilized  it  almost 
to  the  entire  exclusion  of  any  other  technic  and  obtained  very 
good  results  by  so  doing.  He  has,  however,  since  that  time 
done  over  fifty  perineal  prostatectomies. 

Thus  the  man  who  was  perhaps  better  able  to  judge  the 


LOCAL  ANESTHESIA  OF  PERINEUM. 


16^ 


advantages  and  limitations  of  the  Bottini  technic  than  any- 
other  in  this  country  has  given  it  up  in  favor  of  the  perineal 
operation. 

fi''' 


^,77/*"'* 


Fig.  39 

This  figure  illustrates  the  relation  of  the  Inferior  Pudendal  and  the 
Internal  Pudie  Nerves  to  the  Tuberosity  of  the  Ischium.  It 
shows  the  ease  with  which  they  may  be  anesthetized  in  this 
situation. 

It  also  shows  the  structures  emerging  from  the  greater  Sacro- 
Sciatic  foramen  above  and  below  the  pyriformis;  viz.: 

Int.  Pudic  Vessels  and  Nerve. 


.,  (  Gluteal  Vessels. 

Above  -  o        /^i    4.     1  TVT 

Sup.  Glutea  Nerve. 


Below 


Nerves  to  Obturator  Inter- 

nus  and  Gemelli. 
Sciatic  Vessels. 
Sciatic  Nerve. 
Inferior  Gluteal  Nerve. 


CHAPTER  XIV. 
FRACTURES  AND  DISLOCATIONS. 

One  of  the  differences  between  the  treatment  of  fractures 
now  and  the  former  methods  of  treatment  is  that  the  fracture 
is  set  in  a  permanent  dressing  as  soon  as  it  is  diagnosed.  There 
are,  of  course,  exceptions  to  this,  but  as  a  rule  the  "Fracture 
Box"  has  been  discarded. 

Fractures  and  dislocations,  which  were  formerly  spoken  of 
as  compound  or  as  simple,  are  now  referred  to  as  open  and 
closed. 

Open  fractures  and  dislocations  are  always  to  be  kept  as 
surgically  clean  as  possible ;  they  have,  therefore,  a  certain  dis- 
tant relation  to  pathology.  Especially  slender  has  the  thread 
become  which  unites  the  art  of  treating  fractures  to  the  science 
of  medicine  since  the  introduction  of  the  X-ray. 

A  great  many  new  and  undoubtedly  more  comfortable 
dressings  have  been  introduced,  but  in  general  any  dressing  is 
good  if  it  successfully  concludes  the  treatment  of  the  case.  The 
solitary  indication  is  that  a  given  dressing*  must  reduce  the  de- 
formity and  hold  it  reduced. 

Fractures  cannot  be  reduced  and  held  reduced  except  the 
anatomy  of  the  part  be  properly  understood.  One  of  the  most 
interesting  and  instructive  fractures,  from  a  purely  mechan- 
ical standpoint,  is  that  of  the  femur.  There  are  three  planes 
in  which  force  is  exercised  to  produce  the  characteristic  de- 
formity. This  fracture  exemplifies  so  well  the  principle  long 
taught  by  Stimson  that  the  distal-fragment  should  always  be 
put  in  line  with  the  proximal.  Leave  the  proximal  fragment 
to  take  that  position  which  the  conflicting  planes  of  muscle 
force  will  throw  it  into,  and  by  as  simple  a  contrivance  as  pos- 
sible put  the  distal  fragment  in  line  with  this.  Hold  it 
there,  and  the  result  will  uniformly  be  good.  Attempt,  how- 
ever, to  force  the  proximal  fragment  into  line  with  the  distal, 
and  the  result  will  uniformly  be  bad. 

*  Dressing  here  is  used  in  a  general  sense. 


LINEA  ASPERA. 


ur, 


The  position  taken  by  the  proximal  fragment  of  the  femur 
depends  entirely  upon  the  length  of  that  fragment.  This  is 
easily  explained.  The  three  groups  chiefly  concerned  are  the 
adductors,  the  flexors  and  the  abductors  or  external  rotators. 
When  the  fragment  is  short,  as  for  example,  if  the  break  occurs 
from  five  to  seven  centimeters  distal  to  the  lesser  tuberosity, 
all  the  muscular  attachment  of  the  second  and  third  group  is 
inserted  upon  the  proximal  fragment.  Only  a  part  of  the  ad- 
ductor  insertion    is   upon   this   piece   of   bone,   for   it   extends 


Fi<;.  40 
This  shows  the  linea  aspera  pulled  out  sideways. 

throughout  the  entire  linea  aspera.  (See  cut  of  muscles.)  In  a 
fracture,  then,  situated  at  the  point  just  mentioned,  the  posi- 
tion taken  by  the  proximal  fragment  is  that  of  external  rota- 
tion and  abduction  with  flexion.  As  the  line  of  fracture  occurs 
further  and  further  distally,  the  pull  of  the  adductors  becomes 
greater  and  greater,  for  the  reasan  already  referred  to,  until 
at  length  the  adductor  and  the  abductor  pulls  balance.  What 
efifect  upon  the  flexion  of  the  fragment  has  its  lengthening? 
Obviously  the  longer  it  is  the  more  it  is  enshrouded  by  the 
Heavy  vasti  muscles  and  the  leverage  of  the  lengthening  piece 
rapidly  becomes  so  great  as  to  obviate  all  evidence  of  flexion 
in  the  fragment.  This  occurs  at  about  the  same  time  that 
abduction  and  adduction  balance  each  other.  It  is  at  a  point 
about  midway  on  the  thigh.    This  explains  the  figure,  which,  it 


168 


DIFFERENTIAL  OF  FRACTURE. 


Th^ec  /J'sy'^  Chdjr 


will  be  noted,  calls  for  a  Nathan  R.   Smith   splint   until  the 
fracture  reaches  about  the  mid  point  of  the  bone. 

Success  follows  a  strict  adherence  to 
the  principle  that  whatever  the  direction 
of  the  proximal  fragment,  the  distal 
fragment  must  be  made  to  follow  it. 
The  dressings  suggested  in  the  figure 
are  by  no  means  the  only  ones  which 
will  fulfill  the  required  condition.  They 
are  only  examples  of  dressings  suited  to 
the  supposed  conchtions. 

The  Etiology  of  Fracture*  Direct 
Force.  This  is  the  most  frequent  cause 
of  fracture,  particularly  of  short  bones 
and  of  flat  bones.  An  exemplification 
of  it  is  fracture  b}^  a  cart-wheel  having 
passed  over  the  part. 
Indirect  Force.  This  form  of  violence  usually  breaks  the 
long  bones.  For  example,  the  ribs  are  often  broken,  but  they 
rarely  give  way  at  the  point  of  application  of  violence.  It  is 
true  that  they  may  be  crushed  in  by  a  very  heavy  blow  upon 
the  chest  wall  as  of  a  hammer  or  a  club,  but  the  usual  history 
of  this  fracture  is  that  pressure  was  applied  on-  two  opposite 
sides  of  the  body  to  such  an  extent  that  it  was  flattened  until 
the  ribs  gave  way  at  a  point  90  degrees  from  the  application 
of  the  pressure.  Such  forms  of  injury  are  often  inflicted  on 
brakemen  caught  between  cars.  Another  example  of  this  type 
of  injury  is  seen  in  the  bending  and  bursting  or  equatorial 
fractures  of  the  skull  which  occur  at  90  degrees  from  the  point 
of  application  of  the  pressure. 

Muscular  Violence.  Except  in  the  olecranon  and  in  the 
patella,  which  are  really  nothing  more  than  sesamoid  bones, 
this  cause  of  fracture  is  rare.  Baseball  pitchers  do,  however, 
occasionally  break  a  long  bone. 

The  Differential  of  Fracture  rests  upon : 

(1)  History  of  Injury,  (may  be  very  slight  indeed). 

(2)  Pain. 

(3)  Disability:  Lost  or  limited  power. 


^ 


DIFFERENTIAL  OF  FRACTURE.  169- 

!a.   Displacement  and  loss  of  contour. 
b,  Angular  deformity. 
c,   Swelling,  ecch)'mosis,  blebs. 

C     rt,   Bony  irregularity. 
,^.         .      ,         \      b,   False  point  of  motion. 
(0)   Palpation     ,      ^^    Referred  pain. 

[     d,   Linear  pain.      (Important) 

(      L\    Extension  painless;    compression  painful, 

I     /,   Rigidity. 

i  Bone. 
g.   Crepitus  <  Blood. 

(  Tendon. 
(This  sign  is  the  least  valuable  of  all) 

(6)  Compare  with  opposite  side. 

(7)  Mensuration. 

(8)  Tendency  to  recur. 

(9)  X-Ray. 

The  details  of  these  signs  are  as  follows: 

Probably  the  most  important  is 

Pain.  This  is  not  peculiar  to  fracture  at  all,  but,  as  already 
stated,  is  an  invaluable  diagnostic  point  in  many  diseases.  For 
that  reason,  the  giving  of  an  anesthetic,  while  undoubtedly  of 
great  value,  has  this  hmitation  upon  it,  that  it  takes  from  the 
surgeon  this  very  important  natural  sign-post  Avhich  points 
to  something  wrong.  The  importance  of  establishing  a  diag- 
nosis without  an  anesthetic  is  well  seen  in  the  case  of  early 
inflammatory  lesions  of  joints  where  pain  is  often  the  only 
symptom. 

The  pain  of  fracture  has  several  important  characteristics. 

First,  the  ordinary  subjective  pain  incident  to  the  injury. 

Second,  the  referred  pain.  This  is,  of  course,  an  objective 
pain  and  is  elicited  by  the  surgeon  pressing  upon  uninjured. 
regions.  For  example,  if  a  fractured  rib  is  suspected,  pressure 
over  the  two  ends  of  the  rib  will  often  cause  the  patient  to  cry 
out.  On  being  asked  where  it  hurt,  he  will  frequently  point  to 
the  neighborhood  of  the  axillary  line.  Another  good  example 
of  referred  pain  is  occasionally  to  be  seen  in  Pott's  Fracture,. 
where  pressure  on  the  fibula,  ten  or  twelve  centimeters  above 
the  ankle,  or  pressure  on  the  tip  of  the  outer  malleolus  will 
cause  the  ];)atient  to  cry  out.     He  will  refer  the  pain   to  the 


•170  SYMPTOMS  OF  FRACTURE. 

usual  point  of  fracture,  viz. :  four  or  five  centimeters  above 
the  malleolus.  This  objective  referred  pain  of  bones  is  en- 
tirely different  from  the  "referred  pain"  of  nerves,  which  is 
■entirely  subjective. 

Third,  and  very  important,  is  linear  pain.  This  is  consid- 
ered by  many  surgeons  as  a  pathognomonic  sign  of  fracture. 
It  is  well  elicited  by  pressure  along  the  course  of  the  bone 
with  the  butt  end  of  a  pencil.  The  zone  of  tenderness  will  be 
found  in  typical  cases  not  to  be  broader  than  a  pencil  butt. 
This  pain  is  very  sharp,  and,  when  present,  is  of  the  greatest 
value.  It  is  always  present  when  bones  near  the  surface  are 
fractured. 

Fourth,  compression  pain.  This  form  of  objective  pain  is 
of  value  in  differentiating  fracture  from  dislocation.  If  the 
distal  extremity  be  pulled  from  the  proximal,  in  the  case  of 
fracture,  the  two  sharp  ends  of  bone  which  grind  into  each 
other  and  into  the  neighboring  soft  parts  will  be  separated 
and  the  injury  that  they  are  causing  will  be  stopped.  Conse- 
quently the  patient  will  at  once  experience  relief.  If,  on  the 
other  hand,  the  proximal  and  distal  portions  are  pressed  to- 
gether, the  injury  done  will  be  increased  with  a  corresponding 
increase  in  the  patient's  pain.  Dislocation  is  just  the  reverse 
of  this.  In  it  the  soft  parts  are  torn  and  the  hard  parts  are 
intact.  If  you  pull  upon  the  distal  fragment,  it  stretches  the 
torn  soft  parts  and  it  hurts  the  patient.  Pressing  the  fragments 
together,  however,  has  a  negative  effect. 

Ecchymosis  and  Blebs,  when  present,  if  they  can  be  posi- 
tively shown  not  to  have  been  caused  directly  by  the  primary 
injury,  are  of  pathognomonic  importance.  If,  for  instance,  a 
person  is  thrown  from  an  automobile  and  lands  upon  his 
shoulder,  it  hurts  more  or  less  for  a'  number  of  days,  but  no 
further  positive  evidence  may  be  forthcoming.  Perhaps  after 
three  or  four  days  there  will  appear  a  little  subcutaneous 
hemorrhage  in  the  neighborhood  of,  usually  somewhat  internal 
to,  the  acromion.  The  fact,  that  this  was  not  there  before  shows 
that  it  is  not  the  black  and  blue  bruise  of  the  primary  injury, 
but  that  it  is  due  to  blood  which  has  escaped  from  a  broken 
bone  and  which  is  slowly  finding  its  way  to  the  surface.  These 
blood  extravasations  follow   the  fascial  muscular  boundaries 


HOW  TO  LOCATE  THE  TROCHANTER. 


171 


more  or  less  and  are  widely  influenced  by  gravity.  Thus  it  hap- 
pens that  the  ecchymosis  of  a  Pott's  fracture  is  often  found 
over  the  calcaneum  just  distal  to  the  tip  of  the  external  malleo- 
lus. Probably  in  some  cases  the  direction  of  the  blood  ex- 
travasation is  more  or  less  determined  by  the  periostium.  It 
would  be  safe  in  the  supposed  case  of  automobile  accident 
referred  to  above,  to  say,  upon  the  appearance  of  an  ecchymosis 
as  described,  that  the  patient  had  a  fractured  bone. 

Blebs  usually  form  somewhat  later  than  ecchymosis.  They 
are  an  equally  important  sign  of  fracture. 

Because  the  X-rays  are  not  by  any  means  always  avail- 
able, as,  for  example,  in  country  practice,  Blake  considers  that 
they  should  be  held  in  secondary  importance  for  the  diagnosis 
of  fracture. 

Fracture  of  the  Neck  of  the  Femur.  Nothing  can  be  done 
with  this  condition  until  one  is  familiar  with  the  landmarks. 
In  a  child  or  in  a  slender  patient,  it  is  easy  to  get  one's  fingers 
upon  the  great  trochanter.  In  a  big  fat  woman,  however,  it 
is  no  easy  matter  unless  the  exact  position  of  the  trochanter 
in  its  relation  to  a  prominence  which  cannot  be  covered  with 
fat  is  kn,own.  This  is  the  anterior  superior  iliac  spine,  and  the 
following  method  is  a  handy  one  to  enable  the  surgeon  to  place 


rfi- 


,1^       ■r' 


Fig.  42 


173  COMPARISON  WITH  SOUND  SIDE. 

the  tip  of  his  index  finger  upon  the  tip  of  the  great  trochanter^ 
or  rather  to  place  it  -where  it  ought  to  be  without  reference  to 
the  fatness  or  the  leanness  of  the  patient. 

Put  the  patient  flat  upon  his  back.  Stand  by  the  side 
opposite  to  the  injury.  Place  the  fifth  metacarpo-phalangeal 
joint  of  the  hand  which  is  nearer  the  patient's  head  upon  the 
anterior  superior  spine  of  the  injured  side.  Put  the  hand  in  a 
transverse  plane  of  the  body,  and  if  the  patient  be  an  adult 
and  the  surgeon's  hand  be  of  usual  size,  the  tip  of  the  index 
finger  will  be  found  to  lie  directly  upon  the  tip  of  the  great 
trochanter. 

Very  naturally  it  is  not  often  necessary  to  resort  to  this, 
method,  but  as  the  great  trochanter  is  the  all-important  land- 
mark in  determining  hip  injuries,  and  since  in  very  fat  women 
with  unusually  small  bones,  it  is  sometimes  difficult  to  Hnd, 
the  technic  may  occasionally  be  of  service. 

Bryant's  Triangle.  This  is  found  by  dropping  a  vertical 
line  from  the  ant.  sup.  spine  when  the  patient  lies  flat  on  his 
back.  The  line  passes  to  the  table.  A  second  line  is  drawn 
at  right  angles  to  it  from  the  tip  of  the  great  trochanter.  This 
it  will  be  noticed  is  just  about  in  the  line  of  the  pants  pocket, 
and  in  an  adult  is  about  five  centimeters  in  length.  The  hy- 
potenuse of  Bryant's  Triangle  extends  from  the  tip  of  the  great 
trochanter  to  the  anterior  superior  spine.  It  is  of  no  diagnostic 
value  whatsoever,  and  there  is  no  practical  use  of  completing 
the  triangle,  the  important  side  of  the  triangle  being  as  already 
stated,  the  one  which  lies  where  the  seam  of  the  pants  ought 
to  be.  When  the  length  of  this  line  is  determined,  it  should 
be  compared  with  the  length  of  the  corresponding  line  on 
the  well  side  before  any  significance  can  properly  be  attcahecl 
to  it.  Comparison  with  the  sound  side  is  very  important  in 
this  and  in  every  other  fracture.  Individuals  may  vary  very 
widely  from  the  standard,  but  they  are  usually  bilaterally 
symmetrical.  In  other  words,  the  standard  for  the  patient  is 
not  the  hypothetical  one  in  the  examiner's  mind,  but  the  actual 
one,  represented  by  the  patient's  uninjured  side. 

Obviously,  if  there  be  a  fracture  of  the  neck  of  the  femur, 
this  side  of  Bryant's  triangle  will  either  be  very  much  reduced 
in  length,  or  else  it  will  actually  be  a  negative  quantity  the 


COLLES'  FRACTURE.  173 

tip  of  the  trochanter  having  passed  above  the  line  dropped 
from  the  anterior  superior  spine. 

Nelaton's  Line.  This  is  a  somewhat  more  difificidt  meas- 
ure to  make  because  one  has  to  find  the  most  prominent  part 
of  the  ischiatic  tuberosity.  In  very  fat  people  this  is  difficult 
•or  almost  impossible  to  do.  Nelaton  noted  that  a  line  drawn 
from  the  anterior  superior  spine  to  the  great  tuberosity  of  the 
ischium  should  normally  pass  through  the  top  of  the  great 
trochanter.  If  the  tip  of  the  trochanter  lies  proximal  to  this 
line,  there  is  a  fracture,  unless,  owing  to  the  peculiar  construc- 
tion of  the  individual,  a  similar  condition  exists  on  the  unin- 
jured side. 

Colles'  Fracture.  This  is  called  the  "back  door  fracture." 
In  the  old  days  of  New  England,  the  housewives  used  to  throw 
their  dish  water  out  the  back  door  on  the  path  to  the  out- 
houses. Walking  on  the  same  path  an  hour  after,  when  the 
dish  water  had  frozen,  they  frequently  slipped  and  fell.  They 
usually  fell  backwards,  and  putting  their  hand  behind  them  to 
save  their  buttocks,  they  broke  a  wrist.  Passengers  attempt- 
ing to  walk  on  board  ship  during  a  storm  often  fall  in  the  same 
way.  Banana  peels  on  city  pavements  often  cause  this  frac- 
ture. 

There  are  two  interesting  points  to  remember  about  Colle's 
fracture.  First,  almost  any  form  of  treatment  seems  to  work 
well  if  thorough  reduction  be  accomplished  at  the  start.  Un- 
less this  be  done,  and  it  is  surely  most  certainly  accompfished 
under  an  anesthetic,  no  form  of  treatment  will  give  a  good 
result.  The  disability  arising  from  improper  reduction  con- 
sists in  the  patient  not  being  able  to  close  the  fingers.  This  is 
due  to  an  inclusion  of  the  extensor  tendons  in  the  callus.  The 
second  point  of  interest  about  the  fracture  is  that  it  is  the 
only  one  at  which  pressure  at  the  point  of  fracture  is  permis- 
sible. A  pad  is  usually  placed  in  this  position  to  aid  in  pre- 
venting" recurrence  of  the  deformity. 

Fracture  of  the  Clavicle.  The  most  successful  mechanical 
contrivances  are  those  which  follow  nature's  mechanisms  as 
closely  as  possible. 

Erricson,  who  invented  the  marine  propeller,  is  said  to 
have  had  the  idea  suggested  to  him  while  lying  on  his  back 


174  MORPHOLOGY  OF  THE  GIRDLES. 

one  fall  day  under  a  maple  tree.  He  saw  that  the  seeds,  as 
they  fell,  spun  slowly  round  and  round.  He  conceived  the 
notion  that  if  a  piece  of  metal  were  fashioned  in  the  shape  of 
the  seed  and  its  wings,  it  would  drive  a  boat. 

One  of  the  most  remarkable  characteristics  of  medieval 
architecture  was  the  flying  buttress.  Shooting  off  from  the 
sides  of  the  main  building,  these  delicate  structures  seem  so 
frail  as  to  be  for  decorative  purposes  only.  Yet  they  are  so 
proportioned  that  they  support  enormous  weights.  The  pelvic 
and  the  shoulder  girdles  of  man  are  interesting  examples  of 
flying  buttresses.  In  the  pelvis,  adaptation  to  the  upright 
position  and  other  factors  favoring  ossification  have  caused 
that  greater  girdle  morphologically  to  depart  widely  from  the 
buttress,  but  the  principle  of  transmission  of  the  body  weight 
through  the  pelvic  bones  remains  the  same.  In  the  shoulder, 
a  more  perfect  resemblance  to  the  flying  buttress  has  been  mor- 
phologically preserved.  The  clavicle  and  the  scapula  are  the 
integral  portions  of  the  buttress. 

Fracture  of  the  clavicle,  therefore,  is  of  particular  interest 
since  its  successful  treatment  depends  upon  a  recognition  of 
its  function,  which  is  to  hold  the  upper  extremity  out  from 
the  body  against  the  pull  of  the  torso-humeral  muscles  and 
against  gravity.  After  clavicular  fracture  these  forces  tlirow 
the  distal  fragment  (shoulder)  downward,  forward  and  in- 
ward. The  proximal  fragment  by  muscular  traction  is  dis- 
placed upward.  Any  form  of  treatment  is  satisfactory  for  this 
fracture  if  it  holds  the  distal  fragment  in  a  position  directly 
opposed  to  this,  viz. :  upward,  backward  and  outward. 

Fractures  of  the  Skull.  Breaks  in  the  bone-case  of  tKe 
cranium  are  always  confusing.  They  may  for  convenience 
of  description  be  divided,  first,  into  those  which  are  distin- 
guishable by  their  appearance.  They  may  be  depressed  or 
linear.  The  first  is  caused  by  the  application  of  blunt  force, 
and  is  therefore  direct.    The  second  may  be  direct  or  indirect. 

If  the  fissures  are  multiple  and  radiate  from  a  common 
center,  the  fracture  is  sometimes  called  stellate. 

Depressed  fractures  have  to  be  differentiated  from  the 
circumscribed  swelling  which  often  accompanies  severe  local- 
ized scalp  injuries.    This  is  done  by  palpation.    The  examining 


EQUATORIAL  AND  POLAR  FRACTURES.  175. 

finger  in  case  of  the  bone  injury  is  felt  to  pass  over  a  sharp- 
edge  which  is  not  raised  at  all  into  a  depression.  In  the  case 
of  the  scalp  injury,  there  is  a  similar  depression  and  a  similar 
ring  around  it,  .but  the  finger  is  felt  to  rise  as  it  passes  over 
the  ring  before  it  enters  the  depression.  This  rise  is  the  dif- 
ferential between  the  two. 

Indirect  Fractures  of  the  skull  are  not  thoroughly  under- 
stood. They  are  the  so-called  Bending  and  Bursting  fractures 
and  fractures  by  Conte  Coup, 

To  understand  these,  even  if  imperfectly,  it  must  be  re- 
membered that  when  a  blow  is  applied  to  the  side  of  the  head, 
it  is,  mechanically,  as  though  an  almost  corresponding  force- 
had  been  applied  directly  at  the  opposite  pole.  This  force  is. 
furnished  in  obedience  to  Newton's  law  that  bodies  in  motion 
tend  to  stay  in  motion  and  bodies  at  rest  tend  to  stay  at  rest. 
Given  a  skull,  then,  struck  on  one  side,  the  opposite  side  of  the 
skull  being  still,  has  a  very  decided  tendency  to  remain  still. 
The  necessity  of  overcoming  this  tendency  not  to  move  puts 
pressure  upon  the  brain-case.  You  then  have  a  condition  just 
exactly  the  same  as  if  you  had  put  the  head  between  the  jaws 
of  a  vice. 

From  this  point  on  it  is  not  so  difficult  to  understand  how 
the  bending  and  bursting  or  equatorial  fractures,  as  they  may 
be  called,  and  the  contra  coup  or  polar  fractures  may  occur. 

Squeeze  the  jaws  of  the  vice  together  and  fracture  will 
very  likely  occur  along  the  line  of  the  equator,  or  in  other 
words  at  90  degrees  from  the  points  of  application  of  the  pres- 
sure. These  are  the  poles.  In  a  vice,  the  pressure  applied  on 
one  side  is  entirely  counterbalanced  by  the  resistance  of  the 
opposite  jaw.  It  does  not  move  at  all.  The  side  of  the  skull 
which  corresponds  to  the  resisting  side  of  the  vice  does  move 
just  as  soon  as  the  inertia  is  overcome.  Perhaps  it  is  for  this 
reason  that  equatorial  fracture  does  not  always  occur,  but  that 
the  break  is  sometimes  found  to  be  at  a  point  180  instead  of 
90  degrees  from  the  pole  where  the  force  was  applied.  For 
further  explanation  of  these  fractures  see  Stimson's  "Fractures, 
and  Dislocations." 

It  is  important  for  legal  reasons  to  remember  that  a  skull- 
case  may  be  very  widely  broken  without  exhibiting  any  grave 


176  TREPHINE  INDICATIONS. 

early  manifestations.  It  is  not  the  broken  bone,  but  the  result- 
ing brain  injury  or  infection  which  may  cause  death. 

Fracture  of  the  Anterior  Fossa  is  often  characterized  by 
sub-conjunctival  hemorrhage,  by  bleeding  from  the  throat 
and  by  paresthesia  of  the  first  nerve. 

Fracture  of  the  Middle  Fossa  is  characterized  by  a  dis- 
charge through  the  ear  of  cerebro-spinal  fluid.  That  a  given 
discharge  from  the  ear  is  cerebro-spinal  fluid  and  not  blood 
serum,  is  determined  in  two  ways.  First,  its  quantity.  This 
is  often  incredible.  It  may,  in  24  hours,  saturate  a  pillow ;  run 
through  a  mattress  and  drip  to  the  floor.  Second,  by  its  power 
to  reduce  such  a  mixture  as  Fehling's  solution. 

Fracture  of  the  Posterior  Fossa.  The  signs  in  this  case 
are  not  distinctive  and  they  appear  late.  There  may  be  swell- 
ing and  ecchymosis  over  the  region,  but  the  presence  of  symp- 
toms of  cerebral  injury,  with  an  exclusion  of  anterior  and 
middle  fossa  involvements,  are  more  important  features  than 
the  local  ones. 

Trephining  or  Bone  Flap  Operations  are  two  methods 
frequently  employed,  either  to  reach  the  brain  and  its  mem- 
branes or  to  treat  fractures  and  their  complications.  The 
indications  for  trephining  are : 

(i)   For  disinfection  of  bending  and  bursting  fractures. 

(2)  Disinfection  of  circumscribed  fracture  with  splinter- 
ing of  inner  table. 

(3)  Clear  cases  of  local  pressure  in  simple  fracture. 

(4)  Removal  of  foreign  bodies. 

(5)  Arrest  of  bleeding  (middle  meningeal)  and  removal 
of  extravasated  blood. 

(6)  Occasionally  in  simple  depression.  (There  is  a  dis- 
cussion as  to  this  point.) 

(7)  Disinfection  and  evacuation  of  pus  which  appears 
after  injury. 

(8)  Cerebral  abscess. 

(9)  Occasionally  in  traumatic  neuroses. 

(10)  Tumors  and  neuralgias  of  the  fifth  nerve.  (From 
Stimson's  lectures.) 

Pott's  Fracture.  An  interesting  characteristic  of  this 
break  is  that  it  is  often  mistaken  both  by  the  surgeon  and  by 


WHAT  CONSTITUTES  POTT'S  FRACTURE  ?  177 

the  patient  for  a  sprain.  It  is  not  uncommon  to  see  men  whose 
rough  work  renders  them  more  or  less  indifferent  to  minor 
injuries,  walking  around  with  a  well-developed  Pott's. 

The  history  of  such  cases  is  as  follows:  By  jumping  from 
their  truck,  or  in  some  similar  exercise  of  their  usual  duties, 
they  "twist  their  ankle."  The  pain  may  be  severe,  but  they 
continue  to  work.  What  is  the  gross  pathology  of  the  part 
at  this  stage?  There  is  a  fracture  of. the  fibula  four  or  five 
centimeters  above  the  external  malleolus  and  there  is  a  begin- 
ning tear  at  the  lower  extremity  of  the  tibio-fibular  ligament. 
The  tibia  transmits  a  considerable  portion  of  the  weight  of  the 
body  to  the  fibula.  Part  of  this  weight  reaches  the  fibula  at 
the  tibio-fibular  articulation  above,  and  part  of  it  is  trans- 
mitted by  the  interosseous  ligament.  As  soon  as  the  fibula 
is  broken,  all  the  weight  that  is  transmitted  normally  to  the 
bone  by  two  agents  has  now  to  be  carried  by  one.  The  natural 
result  of  this  unusual  strain  on  the  tibio-fibular  ligament  is 
that  it  tears  and  that  a  separation  of  the  two  bones  results. 

As  soon  as  this  is  accomplished,  whether  or  not  the  del- 
toid ligament  has  ruptured,  or  the  tip  of  the  internal  malleolus 
has  broken,  as  often  happens  in  place  of  the  ligamentous  tear, 
the  injury  may  be  denominated  a  Pott's  fracture.  This  is  based 
upon  an  acceptance  of  the  holding  (Stimson)  that  the  exist- 
ence of  any  two  of  the  three  characteristic  lesions,  fibula  break, 
interosseous  Hgament  tear  and  deltoid  tear  shall  constitute 
a  Pott's  fracture. 

The  patient  furnishing  this  pathological  picture  usually 
finds  his  way  into  a  hospital  about  this  time.  He  says  h'e  has 
a  "badly  sprained  ankle."  Upon  what  data  is  it  possible  to 
prove  that  it  is  not  sprained,  but  broken  ? 

Inspection. — Foot  is  "spayed;"  in  other  words,  a  position 
of  extreme  plano-valgus.  There  may  be  (late)  ecchymosis 
over  the  calcanium  on  the  outer  side  of  the  foot. 

Palpation — False  point  of  motion  is  a  very  important  and 
characteristic  sign  of  Pott's.  It  is  obtained  by  putting  the 
thumb  and  linger  in  the  position  of  a  stirrup  and  determining 
whether  the  astragalus  moves  back  and  forth  in  its  mortice. 
Eliminate  normal  motion  between  the  tarsal  joints. 

By  pressure  on  the  tip  of  the  external  malleolus  the  frag- 


178        MODERN  TREATMENT  OF  PATELLAR  FRACTURE. 

ment  may  sometimes  be  made  to  rock.  Referred  pain  may 
sometimes  be  obtained  by  pressing  on  the  shaft  of  the  fibula 
high  up.  Linear  pain  is  usually  very  sharply  marked.  It  is 
sometimes  localized  almost  to  a  line.  Find  it  with  pencil  butt. 
The  treatment  is  dorsal  flexion  with  plantar  inversion. 
The  reasons  for  this  are  obvious.  The  ankle  is  often  so  much 
involved  that  it  becomes  permanently  stiff.  While  walking,  at 
the  termination  of  a  tread,  dorsal  flexion  is  marked.  There- 
fore, unless  the  patient  is  to  certainly  develop  a  flat  foot  after- 
wards, there  must  be  marked  dorsal  flexion.  Flat  foot  is  the 
most  dangerous  sequel  of  Pott's.  The  disability  suffered  from 
it  is  often  complete.  It  arises  from  constant  thump  during 
walking  on  the  ball  of  the  foot.  This  was  never  intended  to 
bear  such  weights,  and  the  inferior  calcaneo-navicular  liga- 
ment soon  gives  way  under  the  strain.  This,  of  course,  only  if 
the  ankle  becomes  stiff. 

Blake  has  shown  that  the  treatment  of  patellar  fracture  is 
best  accomplished  by  a  careful  stitching,  with  an  absorbable 
suture,  of  the  lateral  ligaments  of  the  patella.  The  important 
point  is  to  place  the  stitches  very  close  to  the  bone,  in  a  line 
extending  from  it.  This  method  gives  much  better  results 
than  the  older  one  of  utilizing  silver  wire,  which  inflicts  dan- 
gerous traumatism  on  the  parts  at  the  time  of  operation.  Such 
traumatism  is  an  undoubted  factor  in  favoring  infection,  and 
should  therefore  be  avoided. 

DISLOCATIONS. 

Thumb  dislocations  are  of  three  types.  Stimson  lays 
special  stress  upon  their  importance. 

Incomplete  dislocations  are  really  subluxations.  They  can 
be  produced  and  reduced  at  will. 

Complete  dislocations  are  those  such  as  are  commonly 
seen  on  the  baseball  field. 

Complex  dislocations  are  generally  produced  by  attempts 
to  reduce  the  complete  form.  They  are  characterized  by  a 
button-holing  of  the  head  of  the  metatarsal  bone  between  the 
tendons  of  the  flexor  brevis.  It  can  be  relieved  only  by  open 
treatment. 

The  law  for  the  treatment  of  dislocations  is  that  the  de- 


ALLJS  ON  DISLOCATIONS.  ITQ 

formity  should  be  increased  and  the  head  of  the  bone  be  car- 
ried back  over  the  same  course  through  which  it  made  its  exit 
from  the  socket.  The  object  of  increasing  the  deformity  is  to 
relieve  the  muscular  tension  and  relax  the  part.  That  explains 
in  large  measure  the  complicated  steps  of  Bigelow's  method. 
Allis  has  shown  that,  given  a  knowledge  of  the  gross  pathology, 
the  reduction  of  any  ordinary  dislocation  should  not  be  at- 
tended by  difficulty.  Essential  conditions  to  success  are,  first, 
complete  anesthesia,  and  second,  absolute  immobilization  of 
the  proximal  part. 

Dislocations  of  the  hip  and  shoulder  resemble  each  other 
in  that  the  head  of  the  bone  in  each  case  almost  always  tears 
the  capsule  at  its  lower  boundary.  It  is  weaker  here  than 
above,  undoubtedly  because  it  is  not  necessary  for  it  to  give 
as  much  support  to  the  head  of  the  bone. 

If,  as  is  rarely  the  case,  the  head  of  the  humerus  simply 
slips  through  a  tear  in  the  capsule  and  journeys  no  further, 
this  dislocation  is  sub-glenoid.  If,  however,  as  is  usually  the 
case,  it  does  make  an  excursion  in  the  tissues,  it  almost  always 
migrates  toward  the  coracoid  process.  This  sub-coracoid 
dislocation  is  the  common  one.  Under  the  impetus  of  extra- 
ordinary pressure  the  head  sometimes  journeys  past  the  cora- 
coid to  a  position  beneath  the  clavicle.  This  is  known  as  the 
sub-clavicular  form.  It  is  rare.  Occasionally  the  head,  instead 
of  coming  forward,  is  forced  backward,  but  this  also  is  rare. 

The  differential  scheme  for  fractures  should  be  applied  to^ 
every  variety  of  bone-break.     It  cannot  be  done  here. 


CHAPTER  XV. 
TUMORS,  HERNIA  AND  MALFORMATIONS. 

A  tumor  is  a  solid  swelling  not  the  immediate  result  of 
inflammation. 

Cysts  are  swellings  not  the  result  of  inflammation,  but 
they  are  not  solid.  In  the  case  of  certain  malignant  growths 
such  as  epitheliomata,  there  can  be  little  doubt  that  they  are 
occasionally  the  indirect  result  of  an  inflammatory  process. 
This  frequently  arises  from  chronic  injury. 

Benign  tumors  owe  their  interest  chiefly  to  two  condi- 
tions. First,  they  often  cause  inconvenience  and  occasionally 
death  from  simple  pressure.  Second,  they  tend  constantly  to 
undergo  malignant  degeneration. 

The  borderland  between  benignancy  and  malignancy  is 
vague.  This  must  continue  so  long  as  we  remain  ignorant  of 
the  causes  of  malignancy.  All  benign  tumors  are  not  so  far 
removed  from  the  malignant  forms  as  others,  and  on  the  other 
hand  some  of  the  malignant  tumors,  also  near  to  the  zone 
which  separates  the  two  groups,  are  not  far  removed  from  the 
benign. 

Bland-Sutton's  charming  book  deals  most  interestingly 
with  this  question,  as  with  the  entire  problem  of  tumors,  in  a 
wonderfuTly  interesting  and  simple  manner.  He  approaches 
the  subject  by  the  only  standpoint  from  which  it  can  possibl}^ 
be  understood,  viz. :  that  of  comparative  pathology. 

Granting,  then,  that  there  are  certain  tumors  on  both 
sides  of  the  fence,  about  which  nothing  positive  can  be  said, 
it  may  be  justifiable,  first,  to  give  the  general  characteristics 
of  malignancy,  and,  second,  to  attempt  to  differentiate  between 
a  benign  and  a  malignant  tumor,  always  remembering  that 
the  differential  may  fall  flat  because  of.  the  benign  tumors 
having  assumed  malignant  characteristics. 


MALIGNANT  CHARACTERISTICS.  ISi 

CLINICAL  SIGNS  OF  MALIGNANCY. 

(i)  Rapid  growth.  ! 

(2)  Pain. 

(3)  Position. 

(4)  Adherence  to  skin. 

(5)  Ulceration. 

(6)  Redness  and  heat. 

MICROSCOPIC  SIGNS  OF  MALIGNANCY. 

(i)   Infiltration  of  surrounding  tissues. 

(2)  Arrangement  of  cells. 

(3)  Arrangement  of  blood  vessels. 

(4)  Character  of  blood  vessels. 

(5)  Character  of  cells. 

The  applications  of  these  differentials  are  seen  in  Figs.  26 

27  and  28. 

Aberration  from  normal  developmental  lines  gives  rise  to 
the  so-called  terratomata  and  to  congenital  cysts.  The  best 
description  of  the  origin  of  these  cysts  which  are  relatively 
very  common  is  to  be  found  in  Bland-Sutton's  hand  book. 

Carcinomata  occur  on  the  surface  of  the  body.  There  is 
an  inner  and  an  outer  surface.  Diverticulae  of  the  alimentary 
canal  such  as  the  liver,  the  pancreas  and  the  parotid  gland  lie 
upon  the  inner  surface  of  the  body.  For  this  reason,  and  fur- 
ther because  they  are  actively  functionating  glands,  sarcoma 
in  them  is  rare.  They  are  characteristically  attacked  by  car- 
cinomatous degeneration.     (See  Fig.  35.) 

Sarcomata  occur  within  the  body. 

Sarcomata  of  bone  are  frequent  and  are  interesting.  They 
are  of  two  types,  the  central  and  the  periosteal.  There  is  a 
very  great  deal  of  difference  in  the  treatment  of  these  two 
types.  This  is  because  the  central  sarcomata  are  probably 
(Bland-Sutton)  to  be  ranked  with  myelomata.  These  are 
tumors  on  the  border  line  between  malignancy  and  benignancy, 
built  of  tissue  identical  with  the  red  marrow  of  young  bone. 
It  is  thus  of  great  importance  to  the  patient  whether  the  tumor 
be  centrally  or  peripherally  located,  for  whereas  in  the  first 
case  cure  almost  certainly  results  from  a  simple  curettage,  life 


182 


HERNIA 


in  the  second  case  can  only  be  occasionally  prolonged  by  dis- 
articulation of  the  bone. 

McCosh  (Annals  of  Surgery,  Aug.,  04)  states  that  con- 
trary to  the  usual  belief  Sarcoma  is  most  common  between  the 
30th  and  40th  year.  This  is  based  on  a  careful  study  of  ninety- 
eight  cases,  and  is  at  interesting  variance  with  the  generally- 
accepted  teaching  that  sarcomatosis  is  a  disease  of  early  life. 


'/z  ^IctefhQCfeQj  opnin,^ 


Arises 


Fig.  44 

DIAPHRAGM. 

Ensiform 

Last  6  Ribs  and  tlieir  Cartilages. 

Arcuate  Ligaments. 

Lumbar  Vertebrae. 


Internal  Arcjiate  Ligament. — Continuous  witli  outer  side  of  correspond- 
ing crus  and  from  outer  side  of  body  of  1st  Lumbar,  arching  over  tlie 
Psoas,  to  front  of  transverse  process  of  2nd  Lumbar. 


INTERNAL  HP:RNIA.  183 

External  Arcuate  Ligament.— ^\-on1  of  transverse  process  of  2nd  (with 
slip  from  1st  lumbar  vertebra),  to  apex  of  last  rib,  arching  over  qua- 
dratus  lumborum. 

Right  Crus.—Yxon\  bodies  and  intervertebral  substance  of  3  or  4  upper 
lumbar  vertebrae. 

Left  Cms. From  bodies,   etc.,   of  upper  two  lumbar   vertebrae.        The 

tendinous  portions  of  the  crustae  converge  in  the  mid-line  to  form  an 
arch  (for  Aorta,  Vena  Asygos  Major  and  Thoracic  Duct).  The 
Fibres  from  the  right  pass  in  front  of  those  from  the  left— they  cross- 
open  out— and  recross  after  forming  opening  for  esophagus,  finally 
uniting  with  central  tendon. 

^.   ,  ^  r^        .  -^     \  Sympathetic. 

Right  Crus  transmits  -^  Q^^^^g^  ^nd  lesser  Sphlanchnics. 

y    ,,  r-        ,  .,         (  Left  Sphlanchnic. 

Left  Crus  transmits      -j  ^^^^  Azygos  Minor. 

Central  Tendon.— '^xiusiied.  immediately  below  the  pericardium  istrifoil  in 

shape.     Right  leaf  the  larger. 
Aortic  Opening.— In  mid-line  in  front  of  bodies  of  vertebrae  and  hence 

behind  diaphragm.      Transmits    Aorta— Vena   Azygos   Major  and 

Thoracic  Duct. 

Esophageal  Opening.— Formed,  by  double  decussatior;  of  the  Crura. 

„  .,     (  Eso-pha^us. 

^      Transmits  -j  pj^^^^^^^rastric  Nerves,  (left  in  front) 

Foramen   (2uadratum.—V\SiCe6.  at  junction  of  right  and  middle  leaflets. 

Transmits  Lnferior  Vena  Cava. 
Points  of  Deficiency.— ^^a-ces  of  Larray:    One  on  either  side  of  slip  to 
Ensiform.     (Pus  or  Diaph.  hernia) 

Another  between  attachments  to  11th  and  12th  Ribs. 

Brevier  defines  hernia  as  a  "protrusion  of  an  organ  from 
the  cavity  in  which  it  is  normally  contained."  By  far  the  most 
frequent  form  of  hernia  occurs  through  the  potential  opening 
of  the  inguinal  canal.  The  saphenous  region  is  also  a  frequent 
site  for  external  hernia. 

Internal  hernia,  while  uncommon,  occurs  with  sufficient 
frequency  to  make  a  differential  of  the  utmost  importance.  It 
has  already  been  touched  upon  while  considering  intestinal  ob- 
struction.    The  usual  sites  for  internal  hernia  are  as  follows: 

( 1 )  Foramen  of  Winslow. 

(2)  Aortic,  esophageal  and  other  openings  and  weak  places 
of  the  diaphragm.    See  figure  showing  this  muscle. 

(3)  Duodeno- Jejunal . 

(4)  Cecal  fossae. 

(5)  Sigmoid. 

(6)  Preperitoneal  hernia. 


184  IMBRICATION  METHODS. 

There  are  two  important. points  m  the  technic  of  repairing 
external  herniae.  The  first  is  the  use  of  absorbable  sutures  and 
the  second  is  imbrication.  This  latter  is  the  most  recent  ad- 
vance which  has  been  made  in  the  treatment  of  hernia  and  is 
well  exemplified  in  Mayo's  technic  for  the  treatment  of  ven- 
tral hernia  and  in  Andrew's  modification  of  the  Bassini.  An- 
drews accomplishes  what  Halsted  endeavored  to  do.  Hal- 
sted's  operation,  by  which  the  cord  and  its  appendages  were 
placed  on  the  outer  surface  of  the  external  oblique,  did  not 
work  well  because  the  skin  gave  insufficient  protection  to  the 
cord.  It  is  obvious  that  a  stronger  abdominal  wall  may  be 
made  by  uniting  the  three  muscles  rather  than  by  having  them 
split  by  the  cord.  Andrews  accomplishes  this  tighter  union, 
and,  in  addition,  successfully  protects  the  cord.  He  transplants 
it  to  the  outer  surface  of  the  wound  just  as  in  the  Halsted 
technic  and  then  imbricates  or  folds  fibres  of  the  external 
oblique  over  it. 

In  a  large  direct  hernia,  Blake  sews  the  rectus  to  Pou- 
part's  and  closes  the  internal  oblique  over  it. 


J_77o>'f 


""^Jl: 

•Ter  i^oPam7}£i.r-f<fy 

-Tc^^'. 

•^ai 

s^,n  (7^ 


The  fanciful  resemblance  of  the  Inguinal  Canal  to  a  drum  helps 
one  to  remember  the  coverings. 


INDICATIONS  FOR  BROPHY'S  TECHNIC.  1B5.. 

MALFORMATIONS. 

It  is  interesting  to  notice  that  most  malformations  occur 
along  the  central  line  of  the  body.  We  should,  in  other  words, 
suffer  from  very  few  malformations  were  it  not  that  Nature 
tries  to  make  us  bilaterally  symmetrical.  She  sometimes  fails. 
Starting  in  the  mid-line  of  the  face,  one  of  t4ie  most  fre- 
quent malformations  met  with  is  hare  lip.  This  is  rarely  in  the 
exact  median  line,  being  just  to  the  right  or  left  side  of  it.  It 
may  be  single  or  double.  It  is  rarely  uncomplicated  by  a  more 
extensive  lesion,  but  it  may  exist  alone.  If  this  happily  be  the 
case,  it  is  a  relatively  easy  matter  to  freshen  the  surfaces  and 
sew  it  up.  Failure  of  the  hard  part  to  unite,  however,  usually 
accompanies  it. 

Cleft  Palate.     The  teaching  on  the  treatment  of  this  im- 
portant subject  is  destined  soon  to  undergo  very  important 
modifications.     This  is  due  to  the  success  which  has  attended 
a  radical  operation  for  the  deformity.    Brophy  has  operated  in 
over  one  thousand  cases.     Some  of  his  patients   are   now   ten 
years  of  age  and  the  perfect  phonetic  and  deglutitional  results- 
can  but  eventually  serve  to  bring  the  operation  into  general 
favor.    Brophy  has  photographs  of  cases  which  show  that,  far 
from  there  being  a  deficiency  of  tissue,  as  is  usually  supposed 
to  be  the  case,  tissue  is  present  in  normal  quantity.    The  cleft,, 
therefore,  is  due,  not  to  an  absence  of  tissue,  but  to  a  separa- 
tion of  the  parts.    This  separation  renders  impossible  the  nor- 
mal relation  of  the  upper  to  the  lower  gum,  and  this  prevents 
the  proper  mastication  of  food  when  detentition  is  complete. 
Brophy  therefore  advises  that  in  the  first  few  months  of  life, 
and  never  after  the  sixth,  the  soft  and  easily  molded  bones 
should  be  crushed  in  and  held  in  place  with  lead, plates  con- 
nected by  powerful  sutures.    This  operation  is  contra-indicated 
in  a  child  over  six  months  of  age,  because  ossification  has  sa. 
far   advanced   that  there   is   danger  of  breaking  the   ethmoid 
bone.    This  may  result  in  cerebral  infection  and  death.   Brophy 
says  that  the  mortality  is  almost  zero  if  his  technic  be  carefully 
followed. 

The  older  teaching  was  that  the  operation  of  uranoplasty 
should  be  deferred  until  th^re  was  evidence  of  impaired  phona- 
tion,  the  lip  being  sewed  up  earlier  only  if  the  baby  could  not 


186  THE  MALFORMATION  HIGHWAY. 

nurse.  Brophy's  teaching  is  the  reverse  of  this.  He  believes 
that  the  operation  is  not  one  of  grave  severity  and  urges  that, 
for  the  sake  of  additional  room,  the  lips  should  never  be  closetl 
until  the  bone  deformity  has  been  corrected. 

Passing  downward  along  the  median  line  the  next  point 
of  interest  centers  on  the  persistence  of  the  thyroglossal  duct; 
on  cysts  occurring  in  its  course,  and  upon  the  vaguely  under- 
stood branchial  cysts  and  fistulae.  These  are  most  lucidly 
described  and  illustrated  by  Bland-Sutton.  Blake  considers 
it  possible  that  non-traumatic  esophageal  diverticulae  have  a 
direct  relation  to  branchial  mal-development. 

Further  down,  one  reaches  the  umbilicus.  Here  most  in- 
teresting abnormalities  may  occur.  Through  a  persistence  of 
the  omphalo-mesenteric  duct,  it  is  possible  for  the  contents  of 
the  ilium  to  be  poured  out  at  the  umbilicus.  (Patent  Meckel's 
diverticulum.)  If  the  urachus  persists,  there  is  left  a  free  com- 
munication from  the  umbilicus  to  the  bladder,  and  the  patient's 
urine,  instead  of  passing  out  through  the  urethra,  may  be 
voided  at  the  umbilicus. 

Further  down  the  malformation  highway,  one  reaches  the 
bladder.  Extrophy  is  one  of  the  most  difficult  to  cure  of  all 
surgical  lesions.  This  is  because  plastic  work  is  made  for- 
tuitous by  the  crystalization  of  the  urinary  salts  upon  the 
wound  area. 

Hypospadias  and  epispadias,  which,  as  their  names  imply, 
signify  deficiency  of  the  lower  and  upper  walls  of  the  urethra, 
represent  a  lesion  similar  to,  but  of  less  degree  than  extrophy. 

The  uterus  is  a  very  favorite  site  for  congenital  malforma- 
tions. Women  occasionally  retrograde  to  the  marsupials. 
These  anomalous  vertebrates  possess,  among  other  very  in- 
teresting organs,  a  hicornate  or  double  uterus.  Instead  of  the 
fallopian  tubes  ending  as  they  normally  do,  they  continue 
downv\'ard  through  the  body  of  the  uterus,  thus  forming  two 
cavities. 

The  Rectum  is  not  infrequently  the  scene  of  faulty  or  ir- 
regular development.  The  anus  may  be  imperforate,  due,  sim- 
ply to  the  drawing  across  it  of  a  single  fold  of  modified  skin. 
This  deformity  is,  of  course,  easily  corrected  by  puncture.  The 
normal  rectal  opening  is  brought  about  by  a  dimple  on  the 


RECTAL  DIFFERENTIALS.  187 

surface  which  gradually  deepens  as  development  proceeds  until 
it  reaches  the  end  of  the  hind-gut.  It  is  easy  to  understand 
that  a  very  slight  hit  or  miss  on  the  part  of  Nature  would 
either  not  carry  the  hind  gut  far  enough  down  below  the  sacral 
promentary  to  allow  of  its  coming  in  contact  with  the  dimple, 
or  the  dimple  might  either  not  be  placed  in  just  the  right  posi- 
tion or  be  of  the  requisite  depth.  Further,  the  fusion  of  the 
dimple's  bottom  and  the  termination  of  the  hind  gut  may  not 
take  place.  Imperforate  anus,  therefore,  is  not  uncommon. 
Fear  of  it  is  what  makes  it  necessary  in  all  the  maternity  hos- 
pitals for  the  medical  students  to  record  the  baby's  daily  rectal 
temperature.     Doing  it  once  would  suffice. 

A  recollection  of  the  fusion  of  this  dimple  with  the  gut 
serves  to  keep  in  mind  a  differential  point  of  great  clinical  im- 
portance. Carcinoma  is  known  to  be  most  apt  to  occur  where 
there  is  a  line  of  junction  between  skin  and  mucous  membrane. 
This  line  of  junction  in  the  adult  is  from  three  to  five  centi- 
meters within  the  rectum.  That  is  why,  if  you  can  feel  with 
the  finger  a  stricture  in  the  rectum,  it  is  apt  to  be  malignant.  If 
you  cannot  so  feel  it,  it  is  apt  to  be  syphilitic.  It  is  easier  to 
remember  this  point  because  of  its  developmental  relations 
than  by  brute  memory. 

Over  the  sacrum  or  indeed  anywhere  along  the  course  of 
the  spinal  canal,  but  much  more  frequently  low  down  than  high 
up,  one  sometimes  sees  the  lesion  called  spina  bifida.  This 
congenital  defect  is  due  to  a  failure  of  the  laminae  to  develop 
sullficiently  to  enclose  the  cord.  With  or  without  its  mem- 
.branes,  it  escapes  into  the  soft  tissues.  Radical  treatment  is 
to-day  usually  successful. 

Wens  occasionally  occur  along  the  sagittal  line  of  the  head. 
It  is  dangerous  to  operate  upon  them  in  this  position,  how- 
ever, for  fear  that,  instead  being  wens,  the  tumors  may 
in  reality  he  meningeal  encephaloceles,  the  cerebral  counterpart 
of  the  spina  bifida  of  the  cord. 


CHAPTER  XVI.  * 

ANIMAL  PARASITES. 

Comparatively  few  animal  parasites  cause  diseases  in  man 
which  necessitate  surgical  intervention.  Due  to  improved 
methods  of  diagnosis,  however,  there  have  recently  been  re- 
ported an  increased  number  of  instances  where  certain  animal 
organisms  have  so  invaded  various  parts  of  the  body  as  tO' 
compel  active  surgical  treatment. 

The  platyhelminthes  are  the  chief  offenders,  and  of  these 
the  most  important  are  trematodes,  cestodes  and  certain  of  the 
nematodes. 

Of  the  cestodes,  the  Tenia  Solium  (the  common  pork  tape) 
and  the  Tenia  Echinococcus  (tape  of  the  dog)  are  the  most 
frequent  causes  of  lesions  which  necessitate  surgical  inter- 
vention. 

Or  the  nematodes,  the  Ascaris  lumbricoides  (the  round 
worm)  ;  certain  of  the  filariae,  such  as  the  F.  sanguinis  hominis. 
and  F.  humani  oculi;  and  one  of  the  anguillulidae,  the  anguil- 
lula-aciti,  or  vinegar  eel,  merit  mention. 

The  Hematobium  Bilharzia  is  the  single  trematode  of  any 
human  surgical  importance. 

As  to  the  surgical  significance  of  Protozoa,  little  is  to  be 
said.  Some  cases  of  amebic  dysentery  may  ultimately  require 
surgical  treatment.  (See  colostomy.)  Amebic  liver  abscess 
has  also  been  referred  to. 

The  Tenia  Solium,  unlike  the  T.  mediocanalata,  is  capable 
of  causing  serious  surgical  lesions  in  man.  This  parasite  gains, 
entrance  to  the  body  through  the  patient's  eating  uncooked 
pork,  infected  with  the  cysticercus.  This  produces  in  the  ani- 
mal a  so-called  "measly"  condition  (cysticercus  cellulosae). 
The  cysticercus  develops  in  the  brain,  eye,  heart  and  other  or- 

*  The  subject  matter  of  this  chapter  has  been  kindly  furnished  by 
Dr.  William  R.  Stone.  It  is  abstracted  from  his  ms.  of  a  text-book  on 
Animal  Parasites,  which  is  in  preparation  for  the  press. 


CYSTIC  ERC  I.  189 

gans.  It  is  only  rarely  seen  in  the  liver  and  never  in  the  bones. 
In  the  brain,  the  cysticerci  are  usually  found  in  the  membranes 
of  the  cortex  more  rarely  in  the  brain  substance.  Von  Graefe 
estimates  that  in  the  Berlin  opthalmic  practise  the  cysticercus 
is  observed  in  the  eye  once  in  every  thousand  cases.  In  this 
organ  it  is  most  commonly  located  beneath  the  retina ;  about 
half  as  frequently  it  appears  in  the  vitreous  humor,  and,  rarer 
still,  is  met  with  in  the  anterior  and  posterior  chambers.  When 
in  the  aqueous  or  vitreous  humors  the  movements  of  the  para- 
site's head  may  readily  be  seen. 

Cysticerci  developed  in  the  arachnoid  or  pia  often  have  a 
peculiar  branched  appearance.  This  has  given  rise  to  the  mis- 
leading name  of  cysticercus  racemosus.  Here  the  parasite  may 
■grow  to  great  size  (8-25  cm.)  and  have  many  branches  and 
diverticulae.  This  peculiar  shape  is  probably  due  to  the  pres- 
sure conditions  under  which  it  grows.  In  the  brain  ventricles 
the  parasite  may  attain  the  size  of  a  pigeon's  egg. 

Sometimes  the  cysticerci  develop  in  the  skin,  beneath  the 
cutis,  where  they  produce  small  tumors  the  size  of  a  pea.  When 
present  in  the  skin  or  eye,  the  diagnosis  of  obscure  coincidental 
brain  disease  is  made  easy. 

Unless  early  removed,  cysticerci  in  the  eye  lead  ultimately 
to  the  destruction  of  the  organ,  and,  in  some  instances,  to 
sympathetic  involvement  of  the  other  eye. 

In  the  brain  the  symptoms  are  those  of  any  similarly 
placed  brain  tumor  and  the  only  treatment  is  surgical. 

Tenia  Echinococcus.— Von  Siebold  first  described  this  tape 
worm.  It  is  of  comparatively  small  size  and  possesses  only 
three  or  four  segments.  At  maturity  the  terminal  segment 
exceeds  the  rest  of  the  worm  in  size.  The  parasite  has  about 
forty  booklets  springing  from  a  somewhat  swollen  rostellum. 
These  worms  are  found,  often  in  immense  numbers,  in  the  up- 
per portion  of  the  small  gut  of  the  dog.  When  the  ripe  ter- 
minal segment  breaks  ofT,  it  is  carried  out  in  the  feces.  Either 
during  transit  through  the  dog  or  after  reaching  the  outer 
world  it  bursts  and  liberates  the  contained  ova.  They  are  en- 
closed in  a  tough  chitinous  envelope.  After  finding  their  wav 
into  the  stomach  of  man,  this  covering  is  dissolved  by  the 
combined  action  of  the  body  heat  and  the  gastric  juices.     The 


190  HYDATID  DISEASE. 

embryo,  being  set  free,  trecks  through  the  tissues  of  the  gut 
into  other  organs.    Here  they  begin  asexual  development. 

In  the  earliest  stages  at  which  they  have  been  observed,, 
the  ova  consist  of  solid  spherical  bodies  measuring  0.25  to  0.35 
mm.  in  diameter  and  have  a  striking  resemblance  to  a  mam- 
malian egg.  Their  development  (ontogenetic)  follows  the  early 
stages  of  mammalian  development  (phylogenetic),  but  is  not 
completed  as  in  the  higher  forms.  This  developmental  relation- 
ship is  thought  by  many  to  show  that  vermes  are  not  so  far 
removed  from  ourselves  as  the  differences  in  the  adult  forms, 
would  lead  one  to  think. 

The  "brood  capsules"  and  scolices  arise  from  the  germinal 
layer  as  minute  elevations  by  proliferation  of  the  cells  of  the 
layer.  The  head,  or  scolex,  first  appears  as  a  discoidal  thicken- 
ing in  the  wall  of  the  brood  capsule ;  on  the  tip  of  this  discoidal 
thickening,  the  booklets  and  suckers  of  the  head  are  formed. 

Some  hydatids  contain  no  scolices,  and  the  absence  of 
scolices  is  frequently  associated  with  the  absence  of  daughter- 
bladders.    This  condition  is  known  as  a  sterile  hydatid. 

Hydatid  disease  occurs  in  many  countries.  Iceland  and 
Australia  are  its  chief  homes.  In  Iceland  it  is  estimated  that 
1-16  to  1-58  of  the  entire  population  is  affected  by  this  disease. 
Leuckart  says  that  in  central  and  northern  Germany  the  dis- 
ease is  not  infrequent.  In  China  it  is  extremely  rare.  Osier,  in 
1882,  was  able  to  record  only  sixty-one  cases  for  the  whole  of 
the  United  States  and  Canada.  In  England,  however,  it  is  not 
so  uncommon. 

Symptoms  of  Hydatid  disease.  These  vary  in  different 
portions  of  the  body,  but  when  the  hydatid  cyst  is  situated  in 
an  organ,  interference  with  the  functions  of  that  organ  varies, 
inversely  with  the  ability  of  the  organ  to  expand  at  the  same 
rate  as  the  slow-growing  cyst. 

After  a  hydatid  cyst  has  been  punctured  for  purposes  of 
diagnosis  or  treatment,  an  urticarial  rash  often  makes  its  ap- 
pearance within  a  short  time.  This  is  usually  general,  and  lasts 
from  a  few  hours  to  one  or  two  days.  It  has  been  noticed 
after  the  spontaneous  rupture  of  the  cyst  into  one  of  the  large 
serous  cavities.  With  infection  of  the  cyst,  the.  symptoms  are 
those  of  abscess  and  concomitant  pyemia. 


SURGICAL  TREATMENT  OF  HYDATIDS.  191- 

Diagnosis  is  often  easy ;  at  times  it  is  difficult,  or  even  im- 
possible. The  tumor  is  usuall}^  rounded,  firm,  smooth  ancf 
elastic  without  antecedent  or  present  symptoms  other  than 
those  due  to  its  size.  It  is  yielding  and  imparts  a  thrill  on 
percussion.  A  hypodermic  syringe  should  be  used  to  draw  off 
a  small  quantity  of  fluid,  and  if  this  fluid  is  found  to  contain 
scolices,  hooklets  or  a  piece  of  the  cyst  wall,  the  diagnosis  is 
final.  If  these  are  not  present,  the  character  of  the  fluid  must 
be  depended  upon  to  differentiate  it.  It  resembles  two  other 
fluids  found  in  the  body ;  the  cerebro-spinal  and  that  of  some 
forms  of  hydronephrosis.  An  absence  of  symptoms  referable 
to  these  regions  will  differentiate  the  diseases. 

Treatment. — This  is  always  surgical  and  should  have  for 
its  final  aim  either  (A)  Palliative  measures  which  look  to  the 
death  of  the  parasite,  e.  g.  (i)  Internal  administration  of  drugs, 
(2)  Acupuncture.  (3)  Electrolysis.  (4)  Injection  of  fluids, 
into  the  cyst  after  the  removal  of  some  of  its  contents.  (5) 
Aspiratory  puncture  and  withdrawal  of  the  fluid. 

Or  (B)  Radical  measures  which  aim  at  the  complete  re- 
moval of  the  parasite  :  ( i)  Recamier's  method  :  opening  is  made 
with  caustics.  (2)  Long-continued  drainage  and  evacaution 
through  a  permanent  canula.  (3)  Simon's  method :  double 
puncture  with  small  trochars,  followed  by  incision.  (4)  Various 
forms  of  direct  incision  with  immediate  or  delayed  removal  of 
the  parasite. 

Distribution  of  hydatid  in  the  body. — Thomas,  in  1,900; 
cases  from  various  countries,  finds  that  the  frequency  with 
which  the  different  organs  are  attacked  is  expressed  in  the 
following  percentages:  Liver,  57  per  cent;  lungs,  11.6-10  per 
cent;  kidney,  4.7-10  per  cent;  brain,  4.4-10  per  cent;  spleen, 
2.1-10  per  cent;  heart,  1.8-10  per  cent;  peritoneum,  omentum, 
and  mesentery,  1.4- 10  per  cent. 

THE  TREMATODES. 

Ascaris  Lumbricoides.  Some  time  ago  Dr.  Robert  T. 
Morris  made  a  diagnosis  of  the  presence  of  one  of  these  para- 
sites in  the  vermiform  appendix.  Operation  confirmed  the  diag-. 
nosis. 

In  the  ])athological  laboratory  of  the  University  of  Penn- 


193  FILARIAE. 

sylvania  there  is  a  specimen  of  a  liver  and  gall  bladder  which 
shows  the  bile  passage  to  be  completely  blocked  by  this  organ- 
ism. In  this  case,  the  symptoms  previous  to  death  were  those 
■of  gall  stones.  These  worms  have  also  been  known  to  enter  the 
eustachian  tubes  or  nasal  ducts,  and  through  these  to  have 
found  their  way  to  the  external  world.  Kidney,  spleen,  pleura 
and  urinary  passages  have  sheltered  stray  specimens  of  these 
parasites  at  times ;  they  have  even  been  known  to  escape  by 
the  urethra. 

Filaria  oculi  humani.  Under  this  name  are  included  sev- 
eral minute  flariae,  which,  from  time  to  time,  have  been  found 
either  in  the  crystalline  lens,  in  the  vitreous,  or  aqueous  hu- 
mors. These  filariae  are  identical  with  those  found  in  some 
lower  vertebrates. 

Filaria  Sanguinis  hominis.  The  organism  is  the  cause  of 
chyluria  and  lymph-scrotum ;  Varicose  groin  glands,  chylocele; 
certain  varieties  of  lymphorrhagia,  endemic  lymphangitis, 
orchitis,  and  varieties  of  cellulitis.  Endemic  elephantiasis 
arabrim  is  probably  dependent  upon  the  same  cause. 

The  Filariae  Sanguinis  hominis  are  long,  slender,  trans- 
parent, gracefully  formed,  snake-like  organisms,  which,  when 
seen  under  the  microscope  in  newly  drawn  blood,  exhibit  a 
remarkable  activity.  They  coil  and  uncoil ;  wriggle  and  lash 
about  with  incessant  movements  among  the  blood  corpuscles. 
The  parasite  in  parental  form  inhabits  the  tissues,  lymphatics, 
-or  blood  vessels,  while  the  parasite  in  adolescent  form  circulates 
in  the  blood-stream.  There  are  three  chief  varieties  of  this 
parasite,  but  Patrick  Manson  has  described  five.  Those  most 
-commonly  met  with  are :  F,  diurna,  which  appears  in  the  cir- 
culating blood  during  the  day,  disappearing  during  the  night; 
F.  hocturna,  appearing  during  the  night  and  disappearing  dur- 
ing the  day ;  F.  perstans,  which  is  present  both  day  and  night. 

The  filariae  are  to  be  found  most  often  in  tropical  coun- 
tries, such  as  Brazil,  Mauritus,  India,  China  and  the  West  In- 
dies ;  certain  isolated  cases  have  been  recorded  in  individuals 
living  in  temperate  climates  and  who  have  never  visited  tropic- 
al countries.  Both  sexes  are  liable  to  the  disease.  In  Avomen, 
its  first  appearance  may  date  from  a  pregnancy;  in  men,  very 
often  from  some  unusual  physical  effort. 


SYMPTOMS  OF  CHYLURIA.  193 

Symptoms. — The  characteristic  symptoms  of  chyluria  ap- 
pear suddenly.  There  may  be  retention  of  urine,  which  may 
pass  off  spontaneously.  The  urine  is  milk-white,  pinkish  or 
red,  like  blood.  This  condition  may  last  for  a  few  days,  for 
weeks,  months,  or  even  years.  The  urine  may  then  become 
normal,  only  to  return  at  intervals  to  the  same  condition.  In 
certain  cases  the  glands  of  the  groin  are  found  to  be  prominent 
and  the  ducts  varicose.  The  lymphatics  of  the  scrotum  may 
be  similarly  dilated. 

The  filariae  may  be  found  in  the  urinary  sediment. 

The  presence  of  clots  at  once  distinguishes  chyluria  from 
such  purulent  conditions  of  the  urine  as  are  associated  with 
pyelitis,  abscess  rupturing  into  the  urinary  tract,  and  cystitis ; 
from  phosphaturia,  etc.  In  the  case  of  chyluria  complicated 
by  endemic  hematuria,  the  presence  of  Bilharzia  ova  along  with 
the  filariae  will  clear  up  the  diagnosis. 

Lymph-scrotum  is  almost  a  certain  indication  of  the  pres- 
ence, actual  or  past,  of  F.  nocturna  in  the  lymphatics.  On  in- 
specting such  a  scrotum,  it  is  found  to  be  more  or  less  enlarged, 
thickened,  and  covered  in  places  by  lines  or  groups  of  non-in- 
flammatory vesicles.  The  contents  of  these  vesicles  may  in- 
clude living  filariae. 

Orchitis  is  a  common  complication.  The  condition  known 
as  chylocele  may  be  met  with.  Here  the  tunica  vaginalis  may 
contain  a  milky  fluid,  exactly  similar  in  character  to  that  found 
in  lymph  scrotum.  Chylous  fluids  are  also  found  in  certain 
cases,  in  the  peritoneum  and  pleurae,  as  well  as  in  other  por- 
tions of  the  body. 

Elephantiasis  Arabum  implies  an  elephantoid  condition 
of  the  integument,  in  any  portion  of  the  body.  (See  chapter 
on  Lymphatics.) 

Treatment. — In  the  vast  majority  of  instances  this  is  medi- 
cal. In  certain  cases,  however,  of  lymph-scrotum  and  orchitis, 
the  parasite  having  been  found  to  be  single,  has  been  removed 
by  incision. 

ANGUILLULA  ACITI. 

This  is  the  common  vinegar  eel.  C.  Wardwell  Stiles, 
of  the  Bureau  of  Animal  Industry,  has  reported  the  only  case 


194  BILHARZIA  CYSTITIS. 

in  which  this  parasite  has  made  man  its  host.  This  case  oc- 
cnrred  in  a  woman,  and  the  organism  was  removed  from  the 
patient's  bladder,  where  it  had  produced  an  acute  cystitis.  It 
was  supposed  that  the  parasite  had  gained  entrance  into  the 
bladder  by  means  of  a  douche  containing  vinegar.  This  is 
thought  by  some  laymen  to  be  a  means  of  preventing  concep- 
tion. 

Bilharzia  hematobia.  This  parasite  belongs  to  the  dis- 
tomata,  and  its  chief  interest  surgically  lies  in  its  causation  of 
cystitis.  Its  natural  habitat  is  ethiopic.  It  is  extremely  abun- 
dant in  Egypt,  Axim,  Acra  and  other  places  on  the  west  coast 
of  Africa.  Within  the  past  year  a  case  has  been  discovered  in 
the  French  Hospital  of  New  York  City,  and  was  reported  by 
Chas.  H.  Peck.  The  parasite  is  about  7  to  16  mm.  long,  and  is 
covered  with  fine  tubercles.  It  resembles  threads  of  the  finest 
white  silk,  and  is  usually  unbranched.  The  ova  and  contained 
embryos  are  bright,  translucent,  flattened  not  unlike  a  melon 
seed.  One  end  is  blunt,  but  the  other  is  provided  with  a  sharp 
spine.  The  average  length  is  1-200  to  1-160  of  an  inch,  and  the 
breadth  about  one-half  of  this.  The  shell  is  hard  and  trans- 
parent. The  embryo  lying  within  this  is  covered  with  ciliae, 
which,  when  mature,  may  be  seen  to  move. 

The  Symptoms  are  often  sudden  in  onset  and  come  on 
after  a  period  of  incubation  of  about  four  months. 

Generally  the  urinary  bladder  is  the  first  organ  to  show 
involvement,  though  sometimes  a  false  dysentery  may  be  the 
initial  sign.  If  the  posterior  portion  of  the  bladder  alone  be 
involved,  there  is  but  little  pain.  Most  frequently,  however, 
the  neck  of  the  bladder  and  the  urethra  is  involved,  in  which 
case  there  is  pain  on  micturition,  tenesmus,  irritation  and 
supra-pubic  pain.  There  may  be  priapism,  perineal  pain  and 
seminal  emissions  if  the  prostate  and  seminal  vessices  are  in- 
volved.    General  cystitis  is  rare. 

The  Urine.  Haematuria  does  not  usually  come  on  at  first. 
The  gross  examination  may  show  nothing  but  small,  brilliant, 
scarlet,  pin  point  specks.  Under  the  microscope  there  may  be 
a  few  pus  cells,  blood  corpuscles  and  ova.  Later,  the  urine 
becomes  smoky  and  sometimes  bloody;  especially  in  morning 
specimens.     This  is  due  to  the  presence  of  the  organism,  ova, 


BILHARZIA  HEMATOBIA.  195, 

blood  clots,  corpuscles,  pus  and  crystals  of  various  salts.  In 
course  of  time,  as  the  disease  progresses,  the  numbers  of  or- 
ganisms and  ova  in  the  urine  increase  until  they  may  be  present 
in  thousands. 

Treatment. — This  is  medical,  aiming  at  the  support  of  the 
patient's  strength.  If,  as  is  often  the  case,  a  calculus  forms,  it 
must  be  dealt  with  surgically. 


LIST  OF  HOSPITAL  EXAMINATIONS 

For  1902. 


BELLEVUE  HOSPITAL  (P.  &  S.  Division) 

BROOKLYN  CITY  HOSPITAL 

FRENCH   HOSPITAL 

GERMAN  HOSPITAL 

HUDSON  STREET  HOSPITAL 

J.   HOOD  WRIGHT  HOSPITAL 

MT.   SINAI   HOSPITAL 

NEW  YORK  HOSPITAL 

SENEY  HOSPITAL,   Brooklyn 

ST.   LUKE'S  HOSPITAL 

ST.   JOHN'S  HOSPITAL 


EXAMINATION    PAPERS  FOR  1902. 


BELLEVUE  HOSPITAL   (P.  &  S.  Division.) 
April  5th,  1902 
QUESTIONS  IN  ANATOMY. 
l_Draw  a  cross-section   of  the  middle  of  the  right  arm,  show- 
ing the  relation  of  the  various  anatomical  structures. 
2— Name  the  veins  of  the  neck  which  receive  the  blood  from 

the  head  and  face;  give  their  origin  and  anastomoses. 
3_Describe  the  origin,  course  and  muscular  distribution  of  the 

anterior  crural  nerve. 
4 Name  the  viscera  or  portions  of  same  contained  in  the  fol- 
lowing regions:   Right  hypochondriac,  epigastric,  hypogas- 
tric and  left  iliac. 

SURGERY. 

l_What  swellings  may  occur  around  the  wrist  joint  ? 
2 — Give  symptoms  of: 

(a)  Sacculated  Aneurism. 

{d)   Extra  Dural  Hemorrhage. 
3_Give  causes  and  treatment  of  retention  of  urine. 

PRACTICE. 

l._Write  all  you  know  about  Malig.  Endocarditis. 
2_Treatment  of  Pericarditis  beginning  as  dry  pericarditis  and 
passing  on  to  large  pericardial  effusion. 

MATERIA  MEDICA. 

1 Describe  symptoms  and  treatment  of  carbolic  acid  toxemia 

taken  with  suicidal  intention. 

2 Write  prescription  and  directions  in  full  for  treatment  of 

tape- worm. 

3— Enumerate  the  official  prescriptions  of  Hyoscyamus,  aco- 
nite and  digitalis  and  alcaloids  of  each,  and  give  strength 
and  dose  of  each  preparation. 


200 

BROOKLYN' CITY  HOSPITAL. 

1 — Causes  of  albuminuria  and  some  of  the  conditions  and  dis- 
eases in  which  it  may  occur.  Treatment  of  acute 
dysentery. 

2 — Describe  microscopically  and  macroscopically  the  large 
white  kidney. 

3 — What  are  the  important  clinical  differences  in  course,  prog- 
nosis between  compound  fracture  of  a  limb,  by  direct  and 
indirect  violence. 

4 — Briefly  give  treatment  of  Hallux  Valgus. 

5 — Give  treatment  of  Pelvic  Peritonitis. 

6 — Describe  the   Internal  Oblique  Muscle.      Describe  Ureters, 

7 — Give  evidences  of  pregnancy  as  they  exist  at  the  end  of  the 
third  month. 

Describe  the  conduct  of  the  first  staee  of  labor. 


GERMAN  HOSPITAL. 

Brooklyn. 

ANATOMY. 

1 — -Describe  tonsils  and  give  blood  supply. 

2 — What  muscles  move  the  fingers  and  what  nerves  supply 
these  muscles. 

PHYSIOLOGY. 

1 — What  is  the   chemical  action   of  the  bile  in  the  alimentary 

tract. 
2 — Describe  the  mechanism  of  the  heart's  action,  particularly 

how  the  refilling  of  the  auricle  in  diastole  takes  place. 

MATERIA  MEDICA. 

1 — Give  the  physical  and  chemical  properties  of  atropine,  deri- 
vation and  therapeutic  properties. 

2 — Give  the  remedial  action  on  colds,  the  various  methods  of 
its  application  and  indications  therefor. 

GENERAL  MEDICINE. 

1 — Give  the  causes  and  treatment  of  hemoptysis. 
2 — Give  the  diagnosis  of  variola. 


201 
GENERAL  SURGERY. 

1 — Give  the  differential  diagnosis  between  benign  and  malig- 
nant stricture  of  the  oesophagus. 

2 — Give  the  clinical  signs  and  symptoms  demanding  trephin- 
ing following  head  injury. 

OBSTETRICS. 

1 — State  the  preventative  treatment  of  eclampsia. 
2 — State  the  possible  termination  in   the  mechanism  of  a  face 
presentation. 

GYNECOLOGY. 

1 — State  the  differential  diagnosis  of  a  small  ovarian  tumor  and 

extra  uterine  pregnancy  at  the  tenth  week. 
2 — State  the  etiology  and  symptoms  of  endometritis. 


HUDSON    STREET  HOSPITAL. 

MEDICINE. 

1 — Give    the    differential    diagnosis  between    cerebral    hemor- 
rhage and  uremia. 
2 — Give  the  characteristics  of  sputum  in  : 

(/)   Lobar  Pneumonia. 

(2)  Acute  Bronchitis. 

(j)   Bronchial  Asthma. 

(^)   Pulmonary  Gangrene. 

(5)   Pulmonary  Actinomycosis. 
3 — Give  the  physical  signs  of  Mitral  Stenosis. 
4 — Describe  the  lesions  found  in  fatal  cases  of  malaria. 
5 — Mention  the  causes  and  give  the  symptoms  of  embolism  of 
the  pulmonary  artery  or  its  branches. 

MATERIA   MEDICA  AND  THERAPEUTICS. 

1 — Give  r.ymptoms  (jf  acute  poisoning  by  Nux  Vomica. 

2 — Write,    without    abbreviations,    a  prescription  for  an  adult 

with  acute  bronchitis. 
3 — Give  the  full  official  name  and  dosage  for  administration  ini 


-202 

solution  by  mouth,  of  a  preparation  of  an  alkaloid  of  each 
of  the  following  drugs: 

Nux  Vomica. 

Cinchona. 

Coffee. 

Opium. 

Belladonna. 

4 — Give  antidotes,  stating  whether   physiological  or  chemical, 
of  the  following  poisons : 
Opium. 

Sulphuric  Acid. 
Carbolic  Acid.  , 
Nux  Vomica. 
Bichloride  of  Mercury. 

SURGERY. 

1 — Define  concussion  of  the  brain. 

'2 — Give  the  symptoms  of  compression  of  the  brain  following 
injury  of  the  middle  meningeal  and  hemorrhage  between 
the  dura  and  the  skull. 

-3 — State  the  conditions  possibly  underlying  cellular  emphy- 
sema after  injuries  of  the  thorax. 

4 — Give  the  diagnostic  features  of  strangulated  scrotal  hernia. 

■5 — Give  the  treatment  of  popliteal  aneurysm. 

ANATOMY. 

1 — Indicate  by  diagram  the  guides  to  and  positions  of  the  fis- 
sures of  Rolando  and  of  Sylvius. 

^Z — Give  the  relations  of  the  cervical  portion  of  the  esophagus. 

3 — Describe  the  acromio-clavicular  joint. 

4 — Describe  the  collateral  circulation  developed  after  ligation 
of  the  superficial  femoral  at  the  apex  of  Scarpa's  triangle. 

•5 — Name  the^  structures  in  relation  with  the  ankle  joint,  indi- 
catinQf  their  relations  with  eacli  other. 


FRENCH  HOSPITAL. 

1 — Give  diagnosis  of  acute  pneumonia. 
~2 — Give  the  diagnosis  of  Hemoptysis  and  its  treatment. 
3 — Give  a  prescription  for  acute  articular  rheumatism. 


30B 

4 — What  is  the  diagnostic  significance  of  leucocytosis? 

5 — What  is  the  significance  and  value  of  Widals  reaction? 

6 — Describe  the  management  of  a  case  of  chronic  dysentery. 

7 — Describe  the  axillary  space,  giving  boundries,  contents  and 
relations. 

8 — Give  the  relations  of  the  right  kidney. 

9 — («)  Give  the   differential  diagnosis  of  irreducible  inguinal 
and  femoral  hernia, 
{b)  Describe  Bassini's  operation  for  inguinal  hernia. 

10 — Describe  fibro-myoma  of  the  uterus;  indications  for  surgi- 
cal treatment  and  the  various  methods  for  meeting  them. 


J.   HOOD  WRIGHT    HOSPITAL. 
ORAL. 
1 — Tell  what  you  see  in  specimen  of-urine. 

1 — How  would  you  treat  hemorrhage  from  mouth. 
2 — What  is  the  significance  of  a  headache? 

1 — What  is  the  nerve  supply  of  skin  on  back  of  hand? 

2 — What  is  the  action  and  nerve  supply  of  tibialis  anticus?. 

3 — What  muscle  is  crossed  by  the  Phrenic? 

4 — What  are   the  complications  of  fracture  of  the  arch  of  the 

pelvis? 
5 — What  are  the  objective  signs  of  subcoracoid  dislocation  of 

humerus ! 
6 — How  would  you  treat  retention  of  urine? 

ANATOMY. 

1 — Describe  the  deep  epigastric  artery  and  give  principal  sur- 
gical relations. 

2 — Name  different  ways  by  which  lesser  peritoneal  cavity  may 
be  entered  and  name  structures  and  organs  covered  by 
lesser  peritoneal  sac. 

PATHOLOGY, 

1 — What  causes  influence  the  number  of  polymorpho-neu- 
clear,  neutrophilic  leucocytes. 


204 

SURGERY, 

1 — Give  symptoms  of  perforation  of  ulcer  of  stomach,  princi- 
pal conditions  from  which  it  may  be  differentiated  and  out- 
line of  surgical  treatment. 

MATERIA  MEDICA, 
1 — Digitalis,  dose  and  physiological  action. 

PRACTICE. 

1 — Edema  of  lungs,  causes,  symptoms  and  treatment. 


MT.   SINAI  HOSPITAL. 
Questions  by  Dr.   Howard  Lilienthal. 

ANATOMY. 

1 — The  gall-bladder  and  its  associated  ducts. 
2 — Describe  the  prostate. 

3 — What  is  the  usual  deformity  in  complete  fracture  of  the 
lower  fourth  of  the  femur  and  why  does  it  occur? 

SURGERY. 

1 — Describe  briefly  the  method  of  inducing  anesthesia  by  the 
inhalation  of  Nitrous  Oxide  Gas.      Ether.      Chloroform. 

2 — Describe  the  steps  in  an  aseptic  amputation  of  the  thigh 
through  its  middle  third,  giving  reasons  for  the  methods 
which  you  would  employ. 

3 — A  man  of  fifty  years  of  age,  well  nourished  and  with  a  neg- 
ative past  history  is  admitted  to  the  hospital  after  suffering 
for  forty-eight  hours  with  acute  general  cramp-like  abdo- 
minal pain  which  for  the  past  few  hours  has  become  local- 
ized in  the  right  lower  iliac  region.  The  man  vomited 
several  times  during  the  first  day  and  the  bowels  have  not 
moved  since  the  attack  began.  Urination  is  frequent  and 
rather  painful,  but  little  high-colored  non-albuminous 
urine  being  voided  at  a  time.  The  tongue  is  dry  and 
slightly  brownish.  The  pulse  rate  is  110  and  somewhat 
irregular.  The  temperature  is  100''  F.  There  is  consider- 
able abdominal  rigidity  and  tenderness,  on  palpation  the 
expressions  of   pain   being  more  marked  on  the  palpation 


205 

of  the  right  iliac  region.  No  mass  can  be  felt.  On  per- 
cussion the  greater  part  of  the  abdomen  gives  a  tympanitic 
or  intestinal  resonance  but  there  is  an  area  of  marked  dull- 
ness or  even  flatness  in  the  hypogastrium. 

Discuss    this    case.       Give    diagnosis   and    treatment. 
What  would  you  consider  your  duty  as  House  vSurgeon? 


Questions  by  Dk.  B.   Sachs. 

1 — Give  the  symptoms  of: 

a,  Tabes  Dorsalis. 
b^   Disseminated  Sclerosis, 
r,   Multiple  Neuritis. 

c/,  A  tumor  occupying  the  middle  portion  of  the  left 
anterior  central  convolution. 

2 State  the  various  forms  of  iritis  and  the  treatment  of  each. 

3 Give  the  exact  drug  treatment  in  cases  of  incipient  tuber- 
culosis of  the  lungs,  of  extreme  anemia,  of  constitutional 
syphilis,  of  the  early  stage  of  typhoid  fever. 

Write  a  prescription  calling  for  suppositories  to  be  given  for 
the  relief  of  severe  pelvic  pain. 

Questions  by  Dr.  J.   Rudisch. 

1 Character  of  urine  in  contracted  kidney,  waxy  kidney,  and 

acute  Nephritis. 

2 Changes  in  the  blood  and  urine  in  typhoid  fever. 

3— Differential  diagnosis  between  typhus  and  typhoid. 

4 — Characteristics  of  influenza  pneumonia. 

5_In  what  acute  diseases  are  joint  inflammation   particularly 

apt  to  occur. 
G— Treatment  of  hemorrhage  of  the  bowels  in  typhoid. 
7— Ultimate  results  of  gastric  ulcer. 

8— Causes  of  hypertrophy  of  the  left  ventricle  of  the  heart. 
\) — Diagnostic  features  of  variola. 


306 

NEW  YORK  HOSPITAL. 
ANATOMY. 

1 — Describe  the  lymphatic  system  of  the  breast  and  the : 
(a)  Arrangement  of  axillary  lymph  nodes, 
(d)  Arrangement  of  sternal  lymph  nodes, 
(c)  Arrangement  of  anterior  mediastinal  lymph  nodes. 

2 — Give  the  relations  of  the  Prostate  Gland.     What  is  its  func< 
■  tion? 

3 — With  what  bones  does  the  Os  Magnum  articulate! 

THERAPEUTICS. 

1 — Discuss  the  therapeutic  uses  of  and  the  indication  for  vene- 
section. 
2 — Discuss  Salicylic  Acid  and  its  derivatives. 
(a)   Indications  for  its  use, 

(l?)   Advantages  and  disadvantages  of  three  prepara- 
tions with  dosage  of  each. 
3 — Name  three  drugs  that  may  be  used  as  intestinal  antiseptics, 
with  dosage  of  each  when  so  used. 

PRACTICE  OF  MEDICINE. 
1 — Cholelithiasis. 

(a)  State  the  usual  composition  of  gall  stones. 
{d)  State  the  general  and  local  conditions  which  favor 
the  formation  of  gall  stones. 

(c)  State   the   lesions  produced    in    the    gall    bladder, 

liver  and  adjacent  parts. 

(d)  Describe  the  symptoms  of  biliary  colic. 

(e)  Give    the    differential    diagnosis    between    biliary 

colic  and  other  morbid  conditions  that  may  simu- 
late it. 
(/)   Give  the  preventative  remedial  and  surgical  treat- 
ment. 
2 — Hodgkin's    Disease    (synonyms,    Lymphadenoma,    Pseudo- 
leukemia,  etc.)       Discuss   the     etiology,    symptomatology 
and  treatment. 

SURGERY. 

1 — Retropharyngeal  abscess. 

Etiology,  symptomatology,  operative  treatment. 
2 — Exophthalmic  Goitre  ('Graves'  or  Basedows's  Disease'), 

Etiology,  symptomatology. 


20^ 

METHODIST  EPISCOPAL  HOSPITAL.   (SENEY) 

Brooklyn,  March  26th,  1898. 

WRITTEN  EXAMINATION  FOR  INTERNES. 
ANATOMY. 
1 — Describe  the  esophagus  and  give  its  surgical  relations. 

2 — In  what  respects  do  the  hip  and  shoulder  joints  resemble- 
each  other  and  in  what  do  they  differ  ? 

GENERAL  SURGERY. 

1 — Mention  six  of  the  more  important  complications  that  may- 
attend  or  follow  fractiire  of  an  extremity, 
2 — State  the  varieties,   predisposing  and   exciting  causes,,  and 
,    treatment  of  inguinal  hernia. 

GENITO-URINARY  SURGERY, 

l^Describe  the  etiology  and  pathology  of  chronic  ovaritis. 
2 — Give  the  causes  and  symptoms  of  kidney  abscess. 

PHYSIOLOGY. 

1 — How    much   carbon   dioxide   is   normally    excreted   by    the 
lungs  under  ordinary  conditions  of  exercise,  etc.  ? 

2 — Name   the  more  important  constituents  of  the  gastric  juice- 
and  briefly  describe  gastric  digestion. 

MATERIA  MEDICA. 

1 — State  the  therapeutic  uses  of  colchicum. 
2-^What  is  the  derivation  and  therapy  of  guiacol?' 

OBSTETRICS. 
1 — State  the  treatment  of  transverse  presentation. 
2 — State  causes  and  treatment  of  retained  placenta. 

PATHOLOGY. 

1 — What  are   the  pathological  differences  between  Hodgkin's; 
disease  and  leucocythemia? 

GENERAL  MEDICINE. 

1 — State  the  symptoms  differential  diagnosis  and  treatment  of 
cancer  of  the  stomach. 


•208  ^ 

'2 — What  are  the  symptoms  and  what  is  the  treatment  of  infan- 
tile scurvy? 

March  29th,  1902. 

ANATOMY. 

1 — How  would  you  apply  a  trephine  to  expose: 

(a)  the  mastoid  antrum, 

(d)  the  lateral  sinus  ? 
2 — Give  the  sensory  nerve  supply  of  the  upper  extremity. 

GENERAL  SURGERY. 

1 — Give  the  differential  diagnosis  between  the  different  forms 

of  intestinal  obstruction. 
2 — Give  the  indications   and  contraindications   for  amputation 

in  ^angrene. 
3 — State  the  complications  and  sequelae  96  penetrating  gunshot 

injuries  of  the  chest. 

GENITO-URINARY  SURGERY. 

1 — Enumerate  the  causes  of  hematuria.     . 

2 — Give  the  symptoms  of  transperitoneal  rupture  of  the  urinary 

bladder. 
3 — Describe  the  symptoms  and  complications  of  floating  kidney. 

GENERAL  MEDICINE. 

1 — Describe  the  symptoms  and  course  of  acute  anterior  polio- 
myelitis. 

2 — State  the  varieties,  symptoms,  and  differential  diagnosis  of 
arthritis  deformans. 

OBSTETRICS. 

1 — Give  the  diagnosis  and  management  of  placenta  previa. 
2 — State  the  differential  diagnosis  of  ectopic  gestation. 

THERAPEUTICS. 

1 — Give  the  therapeutic  actioa  of: 
(a)  amyl  nitrite, 
(d)  thyroid  extract. 

PHYSIOLOGY. 

1 — How  do  proteids  differ  from  peptones? 

2 — Describe  the  more  important  functions  of  the  spinal  cord. 


209 
PATHOLOGY. 

1 — Give  the  differential  diagnosis,  as  based  on  an  examination 
of  the  blood,  between  typhoid  fever  and  malignant  endo- 
carditis, and  describe  the  post-mortem  findings  in  both 
diseases. 


ST.    LUKE'S  HOSPITAL. 

INSTRUCTIONS  FOR  CANDIDATES. 
April  7th  and  8th,  1903, 

1 — Each  candidate  is  furnished  with  questions  on  Materia 
Medica,  Practice,  Anatomy  and  Surgery,  for  written  ex- 
amination. 

2 — Assemble  at  Hospital  again  on  Tuesday,  April  8th,  at  2.15 
P.  M  ,  for  practical  examination,  etc. 

ANATOMY. 
1 — Triangle  of  Petit. 
Hi — Nerve  supply  of  trapezius. 
3 — Give  articulations  of  tarsal  bones. 

4 — Through  what  foramina  of  the  skull  do  the  following  struct- 
ures enter  or  leave  the  skull : 

(/)  Middle  meningeal  artery. 
(2)  Internal  carotid  artery, 
(j)  Facial  nerve. 

(4)  9  th  nerve. 

(5)  10th  nerve. 

(6)  12th  nerve. 

MATERIA  MEDICA. 

1 — Treatment  of  opium  poisoning. 
2 — Medical  uses  of  quinine. 
3 — Hydrotherapy  in  typhoid. 

SURGERY. 

1 — Gall  stones,  varieties,  symptoms,  treatment. 
2 — Hydrocele,  varieties,  treatment. 
3 — Spina  Bifida,  varieties,  treatment. 

MEDICINE. 
1 — Mitral  Stenosis,  symptoms,  diagnosis,  treatment. 


210 

ST.   JOHN'S  HOSPITAL. 
Brooklyn. 

ANATOMY. 

1 — Give  the  arterial  supply  of  the  bladder. 
2— Give  the  relations  of  the  duodenum. 

3 — Give  the  structures  divided  in  an  amputation  four  inches 
below  the  knee  joint. 

SURGERY. 

1 — Give  the  symptoms  of  stone  in  the  bladder. 

2 — Describe  Pott's  fracture. 

3 — Give  the  treatment  of  acute  synovitis  of  the  knee  joint. 

GYNECOLOGY. 

1 — Give  the  different  varieties  of  fibroid. 

2 — Give  pathological  conditions  giving  rise  to  menorrhagia. 

3 — Give  treatment  of  1  and  2. 

MATERIA  MEDICA  AND  THERAPEUTICS. 

1 — What  is  Donovan's  Sol.?     Dose?     When  indicated? 

2 — Give  relative  strength  of  Pulv.  Opii.,  Tr.  Opii.  and  Codeine. 

Doses.      Indications  for  use  and  therapeutic  effect. 
3 — Veratrura  Viride.     Official  preparation.    Dose.     Indications 


for  use.      Effect. 


GENERAL  MEDICINE. 


1 — Diphtheria.      Complications.     Treatment. 

2 — Bright's  Disease.     Varieties.      Treatment. 

3 — Cerebro-spinal  meningitis.      Etiology.      Symptoms. 


OBSTETRICS. 


.  1 — Stages  of  labor  and  dangers  attending  each. 
2 — Extra  uterine  pregnancy,  description  and  management. 
3 — Indications  of  the  use   of  forceps.      Describe  high  forceps 
operation. 


LIST  OF  HOSPITAL  EXAMINATIONS 

For  1904. 


BELLEVUE  HOSPITAL  (P.  &  S.  Division) 

BROOKLYN  HOSPITAL 

CHRIST  HOSPITAL 

GERMAN  HOSPITAL 

GERMAN  HOSPITAL,   Brooklyn. 

KINGS  COUNTY  HOSPITAL 

NEW  YORK  CITY  HOSPITAL 

NORWEGIAN  HOSPITAL 

NEWARK  HOSPITAL 

POST  GRADUATE  HOSPITAL 

ROOSEVELT  HOSPITAL 

ST.   FRANCIS  HOSPITAL 

ST.   LUKE'S  HOSPITAL 

ST.   VINCENT'S  HOSPITAL 

SENEY  HOSPITAL,   Brooklyn 

SMITH  INFIRMARY. 


EXAMINATION   PAPERS  FOR  1904. 


BELLEVUE  HOSPITAL  (P.  &  S.   Division) 

SURGERY. 
1— Differentiate  between,  malignant  and  non-malignant  tumors 

of  breast. 
2 — Give  varieties  of  club  foot.     Or  else: 
3 — Give  indications  for  ligation  of  ext.  iliac. 

ANATOMY. 
1 — Describe  rectum  in  following  order: 
(a)  Location  and  extent. 
(d)  Curves. 

(c)  Vessles. 

(d)  Nerves. 

(e)  Important  surgical  relations. 

2 — Describe  circulation  of  mesentery,  give  one  method  of 
treating  same  after  removing  part  of  the  gut. 

PATHOLOGY. 
1 — Give  one  test  for: 

a,  albumin  in  the  urine. 
d,   Sugar       "     "       " 
c,   Bile  "    " 

Give  the  ingredients  used. 

2 — What  are  the  pathological  conditions  for  which  tumor  of  the 
brain  may  be  mistaken,  and  how  would  you  differentiate 
each. 


BROOKLYN  HOSPITAL. 
March  9,  1904. 

1 — Describe  the  symptoms  and  state  the  differential   diagnosis 
of  gall  stone  colic. 

Describe  the  symptoms  of  lobar  pneunomia. 
State  the  action  and  uses  of  digitalis. 


214 

2 — List  the   causes  of  uterine  hemorrhage  and   describe    one 

variety  in  full. 
3 — Give  the  differential  diagnosis  of  two  surgical  lesions  in  the 

lower  half  of  the  right  side  of  the  abdomen. 

What  are  the  most  common  complications  of  strangulated 
hernia? 
4 — Give  the  motor  and  sensory  nerve  supply  of  the  hand. 
5 — Give  the  symptoms  of  tubercular  osteitis  of  the  spine  (Pott's 

disease.) 
G — Give  the  mechanism  of  normal  labor. 
7 — Describe  the  gross  and  miscroscopic  changes  in  pulmonary 

tuberculosis  from  its  incipiency  to  the  early  stage  of  cavity. 


CHRIST    HOSPITAL. 

ANATOMY. 
1 — Describe  a  dorsal  vertebra. 

2 — Name  the  triangles  of  the  neck  and  give  their  boundaries. 
3 — Give  the  anatomy  of  the  biliary  duct. 

SURGERY. 

1 — Describe  purposes  and  technique  of  intravenous  saline  in- 
fusion. 

2 — Give  the  pathology  of  appendicitis. 

3 — What  is  tendo-sinovitis  and  its  treatment,  why  is  it  more 
dangerous  in  the  thumb  and  little  finger  than  elswhere  in 
the  hand. 

Oral  Examination. 

ANATOMY. 
1 — Describe  knee  joint.  ' 

2 — Describe  seventh  cranial  nerve. 
3 — Describe  female  uterus  and  give  relations. 

SURGERY. 

1 — Intestinal  obstructions  (acute)  etiology,  varieties,  pathology 
symptoms,  complications  and  treatment. 

2 — Differential  diagnosis  between  backward  dislocation  of  the 
head  of  the  femiur  and  fracture  of  the  neck. 

3 — Osteomyelitis,  etiology,  symptoms,  pathology  and  treat- 
ment. 


215 
GERMAN  HOSPITAL. 

Oral   Examination. 

Dr.   Abler. 

MEDICINE. 

1 — Causes  of  vomiting. 

MATERIA  MEDICA. 
L — Derivatives,  doses  and  preparations  of  Digitalis,  Opium. 

PHYSIOLOGY. 
1 — Causes  of  heart  contraction. 

PATHOLOGY. 

1 — Microscopic  and  macroscopic  difference  between  Adenoma 
and  Carcinoma. 

Dr.    Kiliani. 

ANATOMY. 

1 — Peritoneum,  anterior  abdominal  wall  and  surgical  anatomy 
down  through  pelvis  and  up  rectum. 

2 — Surgical  anatomy  space  of  Retzius,  pouch  of  Douglas,  un- 
covered rectum,  etc. 

3— Man  lifts  weight,  feels  sudden  sharp  pain  in  abdomen. 
Symptoms  of  shock.     What  would  you  examine  for? 

4 — What  is  hernia.      Most  frequent  contents? 
Why  most  frequent  in  male  adult  ? 
Treatment  and  operations. 

6_Bottini's  Operation.  What  is  it  superseded  by?  (Exercis- 
ing of  P.) 

6— Man  falls  off  house,  lands  on  shoulder,  most  frequent  lesion? 

7_Chief  complication  of,  directly  induced  f.  of  clavicle. 
(Brachial  Palsy.  Art.  Vein  and  non-union.) 

GYNECOLOGY. 
1 — Have  you  ever  seen  a  curettage?     What  is  a  curette? 
2 — What  is  purpose  of  curettage? 
3 — What  are  the  causes  of  endometritis? 


216 

GERMAN  HOSPITAL  (Brooklyn). 

March  21st,  1904. 

Writthn  Examination. 

ANATOMY. 

1 — Describe  the  course  and  distribution  of  the  musculo-spiral 
nerve. 

2 — Describe  the  anatomical  conditions  which  may  render  frac- 
ture of  the  femur  near  the  thigh  especially  serious. 

SURGICAL  ANATOMY. 

1 — Give  the  surgical  anatomy  of  inguinal  hernia. 
2 — Give  the  names  of  all  structures  which  are  severed  in  an 
amputation  through  the  middle  third  of  the  thigh. 

SURGERY. 

1 — Give  the  differential  diagnosis  of  the  two  most  commonly 

observed  tumors  of  the  female  breast. 
2 — Give  the  methods  of  examination,  differential  diagnosis,  and 

treatment  of  an  impacted  fracture  of  the  cervix  femoris. 


KINGS  COUNTY  HOSPITAL. 

1 — Symptoms,  diagnose  treatment  of  tuberculous  meningitis. 

2 — Indications  and  methods  of  inducing  premature  labor. 

3 — Symptoms,  physical  signs  and  treatment  of  pulmonary 
edema. 

4 — What  is  the  blood  supply  of  the  ureter? 

5 — Describe  the  peroneus  longus  muscle. 

6- — In  what  class  of  cases  does  intra-capsular  fracture  of  the 
femur  occur?     For  what  may  it  be  mistaken? 

7 — Give  the  differential  diagnosis  between  a  backward  disloca- 
tion of  the  ulna  and  supra- condyloid  fracture  of  the 
humerus. 

8 — Diagnosis  and  treatment  of  placenta  previa. 

9 — Describe  portal  circulation. 


217 

NEW  YORK  CITY  HOSPITAL. 

April  5th,  1904. 

MEDICINE  AND  THERAPEUTICS. 

1 — a.  Name  the  infectious  diseases  of  bacterial  origin  and  the 
bacterium  producing  each. 

b,  Name  the  exanthemata  and  the  sequels  which  may 

result  from  each. 

c,  Name  those  of  doubtful  bacteriology. 

d,  Name  those  transmitted  by  the  mosquito. 

2 — State  the  differential  features  in  the  temperature  charts  of 
Typhoid,  (second  week),  Pneumonia,  Septicemia,  Miliary 
Tuberculosis,  Pulmonary  Tuberculosis  (chronic). 

3 — Name  two  drugs  which  can  usually  be  depended  on  to  pro- 
duce sleep. 

What  is  the  smallest  dose  of  each  which  is  likely  to  be  ef- 
fective and  the  largest  dose  that  may  be  safely  given? 

4 — How  would  you  treat  acute  gastritis  from  abuse  of  alcohol? 

5 — Write  full  orders  for  a  nurse  to  carry  out  for  one  day's 
treatment  of  a  severe  case  of  typhoid  fever  in  the  third 
week. 

SURGERY  AND  ANATOMY. 

1 — Fracture  of  skull.     (Give  treatment  only  of  the  following) : 
a^   Simple,  no  depression. 

b.  Simple,  with  depression. 

c.  Compound,  with  no  depression. 
d^   Compound,  with  depression. 

2 — Mention  six  different  causes  of  enlargement  of  lymphatic 
glands  above  the  left  clavicle,  and  give  the  proper  treat- 
ment. 

3 — What  anatomical  structures  in  the  finger  determine  the  lo- 
cation of  pus  in  acute  abscess.  Indicate  briefly  the  appro- 
priate treatment  in  each  case. 


OBSTETRICS  AND  GYNEGOLOGY. 

1 — a.   Describe  the  second  stage  of  normal  labor  with  head  in 
position  L.  O.  A, 

b,   How  would  you  diagnose  a  face  presentation  from  a. 

breech? 
c^   What  preparations  and  arrangements  are  necessary 
to  secure  an  aseptic  accouchment? 


'218 

2 — a,  What  are  the  normal  supports  of  the  uterus?  Which  of 
these  is  the  most  important  ? 

b,   State  etiology  of  Pelvic  inflammation  in  woman. 

PRACTICAL. 

1 — T.  B.  Joint:  Pneumonia  with  pleurisy. 

2 — Hepatic  cirrhosis. — A  full  and  very  difficult  examination  at 
the  laboratory,  including  Indican,  Diacetic  acid,  and  for- 
mula of  urea,  etc. 


NORWEGIAN  HOSPITAL. 
March  30th,  1904. 

ANATOMY. 

■1 — Give  inervation  and  action  of  the  Sterno- Mastoid  Muscle. 
2 — Describe  the  course  of  the  Lingual  Artery. 
3 — Describe  the  Prostate  Gland. 

4 — Give  general  course  of   the  External  and  Internal  Iliac  ar- 
teries aud  name  their  branches. 

PATHOLOGY. 

1 — Give  a  list  of  the  items  to  be  noted  in  the  examination  of  a 
twenty-four  hour  specimen  of  urine  in  hospital  practice : 

a.  Chemical. 

b,  Microscopical. 

'2 — Which   items  are   the  most  important  as  an  indication   of 

renal  insufficiency. 
3 — Describe  briefly  apparatus  used  for  a  white  and  red  blood 

cell  count. 
4 — What  are  the   approximate  number  of  red  and  white  cells 

per  cm.  of  normal  human  blood? 

SURGERY. 

1 — How  would  you  treat  a  compound  fracture  of  the  leg. 
'2 — Name  the  causes  of  pus  in  the  urine, 
-3 — Give  the  varieties  of  Hernia.      Describe  one  operation. 

'   GYNECOLOGY. 

1 — Name  the  tumors  of  the  Fallopian  tubes  and  give  the  dif- 
ferential diagnosis. 


219 

NEWARK  HOSPITAL. 
SURGERY. 


1 — Symptoms  and  treatment  of  acute  osteomyelitis. 

2 — Diagnosis  and  treatment  of  suppurative  appendicitis. 


POST  GRADUATE  HOSPITAL. 

1 — Where  would  an  embolus  from  the  mesentery  of  the  ap- 
pendix lodge?     From  a  hemorrhoid? 

2 — What  group  of  lymph  glands  would  be  likely  to  swell  first 
from  a  focus  of  mixed  infection  at  an  incisor  tooth?  From 
t  b  c  infection? 

3 — What  bacteria  live  about  the  roots  of  the  hair  and  escape 
ordinary  disinfection? 

4 — Diagnose  between  gonoccus  and  acute  rheumatic  arthritis. 

5 — What  structure  is  chiefly  involved  in  a  bunion? 

1 — Lobar  pneumonia: — Definition,  etiology,  pathology,  symp- 
toms, physical  signs,  prophylaxis,  treatment. 

2 — Dose  of  tr.  digitalis,  strych.  sulphat,  acetanilid,  morph. 
sulphate  and  toxicology  of  each  drug. 

1 — rt,  What  is  the  relative  indication  for  the  cesarean  section? 
b,   What  is  the  absolute  indication  for  the  cesarean  section? 

2 — Where  does  the  ovum  imbed  under  normal  conditions? 

3 — Termination  of  neglected  tubal  pregnancy? 

4 — Physiological  position  of  the  uterus,  the  bladder  and  rectum 
empty? 

5 — What  form  of  cancer  is  most  common  in  the  body  of  the 
uterus? 


ROOSEVELT  HOSPITAL. 

WRITTEN  EXAMINATION. 
Dr.  Weir. 

Surgical   causes  of  bloody  urine  and  how  to  distinguish 

source. 
Possible  courses  of  extravasated  urine  in  trauma  or  stenosis 
of  deep  urethra. 


320 

Dr.   James. 

Describe  best  method  of  determining  size  of  liver  and  con- 
ditions apt  to  lead  to  error. 
Differential  diagnosis  of  Hemoptysis. 
Dr.    Blake. 

Describe  common  bile  duct.      How  would  you  distinguish 

it  during  an  operation  from  portal  vein? 
What  position  of  appendix  predispose  to  abscess  formation 
and  what  positions  to  general  peritonitis? 

Dr.   Tuttle. 

Differentiate  diagnosis  appendicitis  and  acute  pyosalp. 
Relations  of  ureters  in  female. 

ORAL  EXAMINATION. 
Dr.   James. 

Differential  diagnosis  between  benign  and  malignant   ste- 
nosis of  pylorus. 

Dr.   Jackson. 

What  drugs  produce  cutaneous  eruptions? 
Dr.    Blake. 

Line  of  incision  for  an  excision  of  shoulder  joint,   anatomy 

of  circumflex  nerve. 
Differential    diagnosis    between     benign    and    malignant 
tumor  in  breast  of  woman  of  45. 

Dr.   Weir, 

What   is  spermatocele?     In  what  structure  or  structures 

does  it  arise? 
Indications  for  tracheotomy. 
Part  of  trachea  selected  for  operation. 
How  would  one  enlarge  the  incision  in  a  high  treachetomy? 


ST.   LUKE'S  HOSPITAL. 
ANATOMY. 

1 — Describe  the  pectoralis  major. 
2 — Give  the  nerve  supply  of  the  muscles  of  the  orbit. 
3 — State  essential  difference  between   direct  and  indirect  in- 
guinal hernia. 


221 

SURGERY. 
1 — Aneurism,  definition,  varieties,  surgical  treatment  of. 

MEDICINE. 

1 — Symptoms  of  cirrhosis  of  liver,  due  to  disturbance  of  the 
portal  circulation. 

2 — Symptoms  and  signs  of  malignant  endocardicitis. 

Oral   Examination. 

SURGERY. 

1 — Indications,  temperature,  strength  of  saline  infusion.  Colle's 
Fracture. 

2 — Differential  appendicitis,  gallstone  colic,  renal  calculus. 

ANATOMY. 
1 — Two  vertebrae  to  diagnose,  kind  and  number. 
2 — Ligation  of  lingual  artery. 

MEDICINE. 
1 — Complications  and  treatment  of  typhoid  fever,  third  week. 

MATERIA  MEDICA. 

1 — When  administering  digitalis,  what  symptoms  of  poisoning 
should  you  watch  for  referable  to  the  heart  and  blood- 
vessels ? 

2 — What  doses  would  you  prescribe  so  be  given  three  times  a 
day  of  the  following  ? 

/,   Tinctura  nucis  vomica. 

2^   Vinum  Colchici  Radicis. 

J,   Extractum  Digitalis  Fluidum, 

^,   Liquor  Potassi  Arsenitis. 

5,   Sodii  Phosphas. 

^,   Acidium  Hydrocyanicum  Dilutum. 

7,  Extractum  Belladonnae  Radicis. 

8,  Potassi  Acetas. 


223 

ST.   VINCENT'S  HOSPITAL. 

MEDICINE. 

1 — Dysentery,    varieties,    etiology,    pathology,     complications,, 
diagnosis  and  treatment. 

GYNECOLOGY. 

1 — Describe  varieties  of  fibromata  uteri,  give  symptoms  of  each 
variety. 

SURGERY. 

1 — Differential    diagnosis   between,     subphrenic    and    hepatic 

abscess  and  empyema. 
2 — Between  empyema  of  gall  bladder  and  appendicitis. 

ANATOMY. 

1 — Describe  ligation  of  the  internal  iliac  artery. 
2 — Answer  one  of  the  following: 

a^   Give  relations  of  vessles  in  the  pelvis  of  kidney. 

/;,   Locate  and  describe  the  prostate  gland. 

c,         "        "  "  "    seminal  vesicles. 

Dr.   Aspell. 

Treatment  of  Uterine  hemorrhage,  third  stage. 
Causes  of  uterine  hemorrhage. 
Third  stage  of  labor. 

Dr.    Stewart. 

SuppreiAsion  of  urine. 

Retention  of  urine,_        )     ^^^  ^^      ^^  confused? 

Incontinence  of  urme,  )  -' 

Give  example. 

Resection  of  knee,  lines  of  incision. 

Best  method. 

What  is  arthrectomy? 

What  is  excision  of  a  joint? 

Discuss  leucocytosis  in  various  forms  of  appendicitis. 

Dr.    Bissell. 

Coverings  of  the  testicle. 

Hydrocele  define 

Treatment. 

Cystitis,  treatment. 

(He  wants  perineal  section  and  drainage  if  any  operative 

methods  are  used) 
Diagnosis  of  sarcoma  of  testicle. 


22a: 

Dr.    Ferrer. 

Complications  of  typhoid  fever. 
Most  frequent  sequelae. 
Treatment  of  internal  hemorrhage. 

Dr.    Mandel. 

Slides  of  malaria,  leukemia,   urine  crystals,   filaria,   starch, 

granules. 
Value  of  Diazo,  its  occurrence  and  when. 
Value  of  indican,  drugs  causing  reactions  similar  to  it. 


METHODIST  EPISCOPAL  HOSPITAL  (SENEY), 

Brooklyn,  N.  Y. 

ANATOMY. 

1 — How  would  you  apply  a  trephine  to  expose ; 

«,   The  mastoid  antrum. 

b.   The  lateral  sinus. 
2 — Give  sensory  nerve  supply  of  the  upper  extremity. 

GENERAL  SURGERY. 

1 — Give  the  differential  diagnosis  between  the  different  forms, 
of  intestinal  obstruction. 

2 — Give  the  indications  and  contraindications  for  amputation  in 
gangrene. 

3 — State  the  complications  and  sequelae  of  penetrating  gunshot 
injuries  of  the  chest. 

GENITO-URINARY  SURGERY. 

1 — Enumerate  the  causes  of  hematuria. 

2 — Give  the  symptoms  of  trans- peritoneal  ruptures  of  the  urin- 
ary bladder. 

3 — Describe  the  symptoms  and  complications  of  floating 
kidney 

GENERAL  MEDICINE. 

1 — Describe  the  symptoms  of  and  cause  of  acute  anterior  Poly- 
myelitis. 

2 — State  varieties,  symptoms  and  differential  diagnosis  of  ar-. 
thritis  deformans. 


224 

OBSTETRICS. 

1 — Give  the  diagnosis  and  management  of  placenta  previa. 
3 — State  the  differential  diagnosis  of  ectopic  gestation. 

THERAPEUTICS. 

1 — Give  the  therapeutic  action  of: 

a,  Amyl  nitrite. 

b.  Thyroid  extract. 

PHYSIOLOGY. 

1 — How  do  proteids  differ  from  peptones? 

"% — Describe  the  more  important  functions  of  the  spinal   cord. 

PATHOLOGY. 

1 — Give  the  differential  diagnosis  as  based  on  an  examination 
of  the  blood,  between  typhoid  fever  and  malignant  endo- 
carditis, and  describe  the  post-mortem  findings  in  both 
diseases. 


SMITH  INFIRMARY. 

SURGERY. 

1 — Describe  the  various  steps  in  Pirogoff's  amputation. 
2 — What  is  the  most  frequent  site  of  fracture  of  the  clavicle 
and  describe  a  method  of  treatment. 

ANATOMY. 

i — Describe  the  Brachial  artery. 
2 — Describe  the  head  of  the  femur. 

MEDICINE. 

1 — Of  what  are  gall-stones  composed? 

2 — When  and  where  are  they  formed? 

3 — To  what  symptoms  do  they  give  rise? 

4 — Give  medical  treatment,  prophylactic  and  otherwise. 


225 
MATERIA  MEDICA. 

1 — Give  the  physiological  action,  the  therapeutic  use  and  ad- 
ministration of: 

«,   Veratrum  Viridi  and  dosage ; 
b^  Adrenalin. 

OBSTETRICS  AND  GYNECOLOGY. 

1 — Give  the  diagnosis  and  management  of  an  R.  O.  P. 
2 — Differentiate  between   acute,    salpingitis   and   a    ruptured 
ectopic. 

CLINICAL   PATHOLOGY. 

1 — Describe  three  tests  for  albumin  in  the  urine. 
2 — Describe  method  of  staining  for  tubercle  bacilli  in  sputum. 
Give  ingredients  of  all  reagents  used. 

Oral  Examination. 

SURGERY. 

1— Varieties  of  dislocation  of  head  of  humerus. 
2 — In  what  position  would  you  put  up  a  fracture  of  the  head  of 
the  radius. 

ANATOMY. 

1 — Give  the  branches  of  the  external  carotid. 
2 — Describe  the  lumbar  plexus. 

MATERIA  MEDICA. 

1 — Give  dose  of  tincture  and  fluid  extract  and  digitalis.       Give 

its  therapeutic  use  and  contra  indication. 
2 — Symptoms  and  treatment  of  opium  poisoning. 

MEDICINE. 
1 — Give  treatment  of  uremia. 
2— Give  treatment  of  appendicitis  and  when  would  you  call  in 

surgeon. 
3 — Give  symptoms  of  perforation  in  typhoid. 

OBSTETRICS. 
1 — Give  treatment  of  P.  P.  hemorrhage, 


226 

Practical  Examination. 

MEDICAL  WARD. 

1 — Case  of  chronic  lead  poisoning  to  diagnose  and  give  treat- 
ment. (Case  showed  lead  line  on  gums  and  had  wrist 
drop — no  colic.) 

SURGICAL  WARD. 

1 — Colle's  fracture  to  diagnose  and  put  on  dressing.  Fracture 
had  been  reduced  and  was  about  two  weeks  old. 

LABORATORY. 

1 — Two  urines  to  examine:  Tubercle  bacilli. 
2 — Two  slides  to  diagnose :  Pneumococci. 


ST.   FRANCIS  HOSPITAL. 

Written   Examination. 

1 — a,   Describe  the  mastoid  antrum. 

b,  What  structures   may  be   injured    in    operating   in  this 
region? 

2 — Describe  the  action  of  the  heart  in  diastole  and  systole. 

3 — Mention  some  of  the  pathological  processes  leading  to  en- 
largement of  the  liver. 

4 — Give   the  chief  symptoms  of  lobar  pneumonia  as  differing 
from  serous  pleurisy. 

5 — Give  the  chief  symptoms  of  typhoid  fever  as  differing  from 
those  of  malarial  fever. 

6 — Give  the  symptoms  and  the  treatment  of  fractures  of  the 
neck  of  the  femur. 

7 — What  are  the  causes  of  intestinal  obstruction   (acute  and 
chronic)? 


221 

8— a,  What  aire   the   effects  of   Belladona  on  the   circulation, 
respiration,  intestinal  tract  and  eye? 

b,  Mention  other  drugs  acting  in  a  similar  manner  on  these 

functions. 

9 — a,   State  the  official  preparations  of  digitalis  and  dose  of  each. 
d,   Discuss  briefly  the  effect  of  this  drug  upon  the  circula- 
tion and  kidney. 

c,  What  symptoms  or  physical  signs  would  indicate  its  use 

in  heart  disease? 


Dr.    Downing. 

1 — Causes  of  convulsions? 

2 — Causes  of  vomiting. 

3— Causes  of  dyspnea, 

4 — Changes  in  blood  in  anemias  and  leukemias. 

5 — 'Symptoms  of  cerebro-spinal  meningitis. 

Dr.    Lloyd. 

1— Structures  to  be  avoided  in   doing  a  pan-hysterectomy  and 
and  their  relations  to  the  uterus. 

2 — Relations  of  deep  epigastric  artery  to  external  and  internal 
abdominal  rings. 

3 — Relation  of  axillary  artery. 

4 — Femoral  ring,  describe. 


Dr.    Kammerer. 

1 — Causes  of  stricture  of  rectum. 
2 — Causes  of  swelling  of  lymph  glands  of  neck. 
3 — Tumor  of  the  breast,  varieties. 

4 — Pathology  of  intestinal  obstruction  (gangrenous  and  non- 
gangrenous). 

Dr.    Seibert, 

1 — Given  temperature  of  104-lOG''  F.  What  may  it  be.  Ans. 
Pneumonia,  follicular  tonsilitis  or  malaria.  Every  year 
every  man  gets  this  question. 


238 

Dr.    Switzer. 

1 — Digestion  of  meat,  proteid  and  fat. 

2 — What  food  contains  largest  amount  of  glycogen? 

3 — In  what  disease  is  the  glycogen  storing  functions  of  the 
liver  disturbed? 

4 — Where  is  the  glycogen  then  found? 

5 — Tests  for  same. 

6 — What  drugs  reduce  Fehling's  solution? 

7 — Causes  of  intestinal  hemorrhage. 

Dr.    Warren. 
1 — Antidotes  for  arsenic,  phosphorus  and  mercury. 

2 — Effects  of  strychnine.      Causes  of  death  from   strychnine 
poisoning. 

3 — Hives  Syrup. 

4 — Tartar  Emetic. 

5 — Preparations  of  Iron. 

6 — Preparations  of  mercury. 


INDEX. 


Abbe's  fish  line  treatment,  115 
Abbe,  on  radium,  124 
Adenoma,  123 
Ampulla  of  Vater,  153 
Andrew's  technic,  184 
Aneurisms,  differential,  31,  33 
Aneurisms,  27 

''  pathology  of,  39 

Angiotribe,  43 
Animal  parasites,  188 
Appendicitis,  135 

differential,  137,  138 

"  invagination  of,  140 

recurrent,    diff.,  155 

B 

Banti's  disease,  150 
Bilharzia  hematobia,  194 
Bevan,  on  cryosopy,  157 
Bladder,  160 
Bladder  stones,  161 
Blake,  on  diverticulae,  186 

"     treatment  of  patellar  fracture,  78 

"     value  of  X-ray,  171 
Bland-Sutton.  180 
Bloody  urine,  160,  161,  163 
Bone  pressure,  spinal  differential,  113 
Bottini's  operation,  164 
Brain  hemorrhage,  102 
Breast,  malignant  diseases  of,  120 
Brewer,  classification  of  stones,  162 

"        on  hernia,  183 

"        on  gall  ducts,  147 

"        method  closing  arterial 

wounds,  38 

"        reference  to  sepsis,  65 

Brophy's  technic,  185,  186 


Bryant's  triangle,  173 
Burn  contracture,  differential,  51 
Bursae,  differential,  33 
•  "       53 


Calcium  chloride,  37 
Capillary  formation,  23 
Carcinoma,  122,  181,  187 

"  of  liver,  152 

"pyloris,  diff.  129,  130,131 

"  "  rectum,  diff.,  14S 

Celiac  axis,  125 

Cerebral  abscess,  107 

"       diff.,108,  109, 110,  111 

"       tumor,  diff.,  108, 109, 110,  111 

Cestodes,  188 

Chancroids,  differential,  86,  87 

Chemotaxis,  20,  25 

Child,  on  Bursae,  53 

Cholangitis.  153.  138;  diff..  139 

Cholecystitis,  diff.,  139,  130,  131 

Chyluria    58,  193 

Cleft  palate,  185 

Cloudy  swelling,  18,  34 

CoUe's  fracture,  173 

Colon,  140 

D 

Dawbaru,  appendix  technic  128 

"         scheme   for  aneurism   liga- 
tion, 35 
"        on  starvation,  124 

Decortication  vs  capsule  section,  159 

Degeneration  of  benign  growths,  131 

Diapedesis,  17 

Dislocations,  178 

Diverticulae,  115 


230 


INDEX. 


Dunham,  method  of  passing  stricture, 

115 
Duodenal  relations,  137 

ulcer,  138 
Dupuytren's  contracture,  49 

"      ,       diff.,  51 
Dry  productive  inflammation,  34 


E 

Echinococcus,  189 

Ectopic,  right  ruptured,  diff.,  137,  138 
Emerson,  on  decortication,  159 
Empyema  117;  differential,  148 
Epiphysitis,  73;   differential,  81 
Epithelioma,  differential,  86,  87,  88 
Esophagus,  115 

"  diverticulae,  115,  116 

Extrophy,  186 


Fasciae,  48 

Ferguson,  A.  H.,  on  decortication,  159 

Filariae,  192 

Fractures,  166 

of  clavicle,  173,  174 

of  patella,  178 

of  skull,  174 


H 


Harris'  segregator,  157 
Hematuria,  160 
Hemorrhoids,  differential,  143 
Hernia,  183 

"        internal,  183 
Herpes,  differential,  86,  87 
Hydatid  disease,  190 
Hydrophobia,  diff.,  67,  68,  69. 
Hypodermoclysis,  63 
Hysterical  spine,  diff.,  78,  79,  80 


I 


Imbrication  methods,  184 

Inflammation,  16 — 26 

Infusion,  63 

Intestinal  obstruction,  143, 143, 144, 145 

Invagination  of  appendix,  140 

Ischio-rectal  fossa,  92;  abscess,  diff., 
94,  95 


K 

Kidney,  153 

"       nephropexy,   155 

"      prolapsed,  differential,  155 


G 


Gastro-duodenal  ulceration,  chronic, 
differential,  152 

Gastro-enterostomy,  133 

Gastritis,  differential,  155,  156 

Gastrostomy,  134 

Gall  bladder,  147 

Gall-stones  of  common  duct,  differ- 
ential, 129,  130,  131 

Genito-urinary,  153 

Glands,  55 

Goodfellow,  on  prostate,  164 

Gonorrheal  arthritis,  diff.,  89,  90,  91 

Grand-mal,  differential,  99,  100 

Granular  change,  18 

Gravitation  diseases,  40 

Gumma,  differential,  31,  32,  33 


Labial  chancre,  differential,  86,  87 

Laminectomy,  113 

Leucocytosis,    diseases  characterized 

by  absence  139 
Linea  aspera,  167 
Liver,  147 

abscess,  differential,  148 
"       carcinoma,  diffei-ential,  152 
Loose  body  in  joint,  diff.,  89,  90 
Lumbar  plexus,  45 
Lupus,  106 
Lymphactic  ducts,  57,  58 

"  of  female  genitals,  59 

Lymphactic  glands,  55 
Lymphactic  vessels,  55 
Lyssophobia,  differential,  67,  68,  69 


INDEX. 


231 


M 

Madyl's  operation,  161 

Malformations,  185 

Malignancy,  71,  142 

Matas'  artificial  respiration,  115 
massive  infiltration,  164 
operation  for  aneurism,  87 

Mayo,  on  hernia,  184 

McCosh,  on  sarcoma,  182 

Median  nerve  section,  diff.,  51 

Meningitis,  diff.,  108,  109 

Muscles,  47 

"        contractures,  48 

N 

Nelaton's  line,  173 
Nematodes,  188 
Nephrolithiasis,  difif.,  155,  156 
Nephropexy,  155 
Nerves,  45 
Nevi,  43 

"      capillary,  43 

"      cavernous,  43 

"      Wyeth's  hot  water,  44 

O 

Ochsner's  treatment  for  appendicitis, 

139 
Occupation  diseases,  53 
Opie  on  pancreas,  152 
Osteomyelitis  differential,  81 
Otitis  media,  106,  107 


Pancreas,  relations  of,  150 

Pancreatitis,  chronic,  152 

Papal  benediction,  49 

Paracentesis,  117 

Perineum,  local  anesthesia  of,  165 

Perineal  prostatectomy,  164 

Phagocyte,  25 

Phebitis,  38,  39 

Pleura,  limits  of,  114 

Popliteal  space,  28,  29,  30 

Pott's  disease,  differential,  78,  79,  80 

Productive  inflammation,  19 — 25 


Pre-patellar  bursitis,  53 

Prolapsed  kidney,  differential,  155,  156 

Prostate,  163 

Prostatitis,  differential,  94,  95 

Prostatectomy,  164 

Pus,  23,  24,  25 

Pyloric  stenosis,  133 

R 

Radium,  124 
Rectum,  186 
Renal  decortication,  159 
relations,  154 
''      sepsis,  158 
Rheumatic  arthritis,  diff.,  89 
Rheumatism,  diff.,  74 — 78 

of  ankle  joint,  diff.,   76 
Round  cell  zone,  20,  21 


Salpingitis,  right  sided,  diff.,  137,  138 

Sarcoma,  spinal,  diff.,  112 

Scar,  19 

Scoliosis,  differential,  78,  79,  80 

Schede's  moist  blood  clot,  29 
"      .  operation,  40 

Septic  arthritis,  differential,  81,  82 

Shock,  61 

Space  of  Retzius,  diff.,  94,  95 

Spinal  sprain,  diff.,  78,  79,  80 

Spleen,  149 

Spondylitis,  78,  79,  80 

Starvation,  124 

Static  spray,  24 

Stomach,  132 

"  pyloric  stenosis,  133 

Sub-phrenic  abscess,  diff.,  148 

Syphilis,  83 

of  ankle  joint,  diff.,  76,  77 
labial  chancre,  diff.,  86,  87 

Syphilitic  coxitis,  diff.,  74,  75 


Temperature  table,  66 
Tendons,  51 

"  transplantation,  53 


233 


INDEX. 


Teno-synovitis,  52 

Terminations,  56,  57 

Testicular  differentials,  162 

Tetanus,  differential,  68,  69 

Tetany,  69 

Tinker,  42 

Tinker,  on  prostates,  164 

Toxicity,  raised  by  pressure,  136 

Transverse  myelitis,  diff.,  112 

Trematodes,  188—191 

Trephine  areas,  103 

"        indications,  176 

Tuberculosis,  69 

ankle  joint,  diff.,  76,  77 
arthritis,  diff.,  89,  90,  91 
coxitis,  diff.,  74,  75 
"  meningitis,   differential, 

108,  109,  110,  111 

Tuffnell's  treatment,  36 

Typhoid,  differential,  108,  109,  110,  111 
"        surgery  of  ulcers,  135 

U 

Ulcer-bearing  pyloric  funnel.  128 
Ulcer  of  pyloric  funnel,   differential, 
129,  130,  131 


Ulnar,  nerve  section,  differential,  51 
Ureteral  catheterization,  157 
Uretero-ureterostomy,  160 
"       -vesical  valves,  161 
Urinary  segregation,  157 

V 

Varicocele,  41 
Varicose  veins,  40 

W 

"Walled  off",  18,  19,  25,  71,  107,     10 

Weir,  marsupialization,  141 

Wens,  187 

Wet  productive  inflammation,  24,  25 

Wyeth's  treatment  of  Nevi,  44 


X 


X-Ray,  123,  157,  166 


Young,  on  prostates,  164 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

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Surgical  differentials 


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